/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---leukemia-and-lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---leukemia-and-lymphoma/name-123895-en.cckm

20180104

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100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Leukemia and Lymphoma

CSC HEM Inotuzumab Ozogamicin Ver 1-3-18 (HL 6526)

CSC HEM Inotuzumab Ozogamicin Ver 1-3-18 (HL 6526) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia and Lymphoma


CSC HEM INOTUZUMAB OZOGAMICIN VER: 1-3-18 –  Properties
Pre-Cycle –  12/27/2017 through 1/2/2018 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 12/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
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
Treatment Conditions
Treatment Condition A
Verify ECG obtained.
Take Home Medications
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 1 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-5, 1 X DAILY starting S, Local Printer
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth every Mon,Wed,Fri., 1 tab, Disp-12 tab, R-5, EVERY MON, WED, FRI starting S, E-Prescribe
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. until ANC greater than 500 after nadir., 500 mg, Disp-14 tab, R-0, 1 X DAILY
starting S, Local Printer
Cycle 1 –  1/3/2018 through 1/23/2018 (21 days), Planned
Day 1, Cycle 1 –  Planned for 1/3/2018
Treatment Plan Information
Reference Information (1)
B-ACUTE LYMPHOBLASTIC LEUKEMIA: Kantarjian HM, et al. N Engl J Med 2016;375(8):740-53.
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for Peripheral Blast Count greater than 10,000/µL or ALT greater than 2.5 X ULN
or AST greater than 2.5 X ULN or Total Bilirubin greater than 1.5 X ULN.
Treatment Condition A
Verify ECG obtained.
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,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 2 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 3 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.8 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
Day 8, Cycle 1 –  Planned for 1/10/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 4 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 5 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 1/17/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 6 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 7 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  1/24/2018 through 2/20/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 1/24/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 8 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Total
Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 9 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) *** mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Patients who achieve CR or CRi: dose = 0.5 mg/m2
Patients who do NOT achieve CR or CRi: dose = 0.8 mg/m2
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
Day 8, Cycle 2 –  Planned for 1/31/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 10 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 11 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 2/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 12 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 13 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  2/21/2018 through 3/20/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 2/21/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 14 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Total
Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 15 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) *** mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Patients who achieve CR or CRi: dose = 0.5 mg/m2
Patients who do NOT achieve CR or CRi: dose = 0.8 mg/m2
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
Day 8, Cycle 3 –  Planned for 2/28/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 16 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 17 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 –  Planned for 3/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 18 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 19 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  3/21/2018 through 4/17/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 3/21/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 20 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Total
Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 21 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) *** mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Patients who achieve CR or CRi: dose = 0.5 mg/m2
Patients who do NOT achieve CR or CRi: dose = 0.8 mg/m2
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
Day 8, Cycle 4 –  Planned for 3/28/2018
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 22 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 23 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 –  Planned for 4/4/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 24 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 25 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  4/18/2018 through 5/15/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 4/18/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 26 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Total
Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 27 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) *** mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Patients who achieve CR or CRi: dose = 0.5 mg/m2
Patients who do NOT achieve CR or CRi: dose = 0.8 mg/m2
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 28 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, Alkaline Phosphatase, AST, ALT;
CHEMOTHERAPY ROOM APPOINTMENT inotuzumab ozogamicin for 150 minutes.
Day 8, Cycle 5 –  Planned for 4/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 29 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 –  Planned for 5/2/2018
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 30 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 31 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  5/16/2018 through 6/12/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 5/16/2018
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 32 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY:
inotuzumab ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days;
COURSE: 1 cycle followed by THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who
achieve CR or complete remission with incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1
(patients who do not achieve CR or CRi), 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 28 days;
COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell
transplant, the recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A
third cycle may be considered for those patients who do not achieve CR or CRi and minimal residual
disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Total
Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 33 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 34 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) *** mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Patients who achieve CR or CRi: dose = 0.5 mg/m2
Patients who do NOT achieve CR or CRi: dose = 0.8 mg/m2
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Total Bilirubin, Alkaline Phosphatase, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT
inotuzumab ozogamicin for 150 minutes.
Day 8, Cycle 6 –  Planned for 5/23/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 35 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Monitor patients closely for infusion reactions
during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 36 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 –  Planned for 5/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: CD22 (+) Acute Lymphoblastic Leukemia, B-Cell Precursor (Relapsed/Refractory); THERAPY: inotuzumab
ozogamicin 0.8 mg/m2 IV Day 1, 0.5 mg/m2 IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by
THERAPY: inotuzumab ozogamicin 0.5 mg/m2 IV Day 1 (patients who achieve CR or complete remission with
incomplete hematologic recover (CRi)) or 0.8 mg/m2 IV Day 1 (patients who do not achieve CR or CRi), 0.5 mg/m2 IV
Days 8 and 15; CYCLE LENGTH: 28 days; COURSE: up to 5 cycles.
NOTE: Due to severe veno-occlusive disease risk, for patients proceeding to hematopoietic stem cell transplant, the
recommended duration of treatment with inotuzumab ozogamicin is up to 2 cycles. A third cycle may be considered for
those patients who do not achieve CR or CRi and minimal residual disease (MRD) negativity after 2 cycles.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ALT greater than 2.5 X ULN or AST greater than 2.5 X ULN or Total Bilirubin
greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 37 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to inotuzumab ozogamicin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications. Monitor
patients closely for infusion reactions during and for at least 1 hour after the end of infusion.
Monitoring Parameters (1)
Monitor patient for signs and symptoms of VOD (elevations in Total Bilirubin, hepatomegaly which may be painful,
rapid weight gain, ascites, etc.). Permanently discontinue inotuzumab ozogamicin if VOD or other severe liver toxicity
develops. Monitor patient for signs and symptoms of infection, bleeding/hemorrhage, or other effects of
myelosuppression.
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 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CUSTOM chemotherapy bag/inj NF
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 38 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

1 each, Intravenous, ONCE, 1 dose Starting when released
inotuzumab ozogamicin (BESPONSA) 0.5 mg/m2 = *** mg in 50 mL NS. Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
1/3/2018 8:13:42 AM Page 39 of 39
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org