/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-96846-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC Hem CLL/WM Ibrutinib(28D:1-28) VER 10-3-16 (HL 5227)

CSC Hem CLL/WM Ibrutinib(28D:1-28) VER 10-3-16 (HL 5227) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia and Lymphoma


CSC HEM CLL/WM IBRUTINIB(28D:1-28) VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
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+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 1 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth once daily for 7 days, Disp-7 tab, R-0, starting S, Local Printer
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LYMPHOMA: Byrd JC, et al. N Engl J Med 2013;369(1):32-42.
Reference Information (2)
WALDENSTRÖM MACROGLOBULINEMIA: Treon SP, et al. N Engl J Med 2015;372(15):1430-40.
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or AST greater
than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 2 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): ibrutinib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Take Home Medications
Note to All Staff (1)
Drug absorption of ibrutinib may be increased greater than or equal to 2-fold when ibrutinib is taken with food. Consider having
patient take ibrutinib on an empty stomach, particularly in event of suspected drug-related side effects that may be dose-related.
ibrutinib (IMBRUVICA) 140 MG cap
Take 3 caps by mouth one time daily. Swallow caps whole with water at approximately the same time each day. Do not open, break
or chew caps., Disp-90 cap, R-0, starting S, Local Printer
Follow-Up
DAY 3 FOLLOW-UP
LABS: Potassium, Phosphate, Calcium, Uric Acid, Total LD, Creatinine.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium and Uric Acid.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium and Uric Acid.
DAY 29 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Total LD.
Lab Only - Day 3, Cycle 1 – Planned for 11/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
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
POTASSIUM
Expected-S+2 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+2 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+2 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+2 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+2 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+2 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 3 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
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
URIC ACID
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 4 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which
does not signify disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of
ibrutinib treatment and may persist for several weeks on treatment.
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
URIC ACID
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 5 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or AST greater
than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ibrutinib will be ordered through the medication activity after the initial order.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 6 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Total LD.
Lab Only - Day 15, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 7 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or AST greater
than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 8 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ibrutinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Total LD.
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
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+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 9 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or AST greater
than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ibrutinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Total LD.
Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 10 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or AST greater
than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 11 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ibrutinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Total LD.
Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma/Waldenström Macroglobulinemia; THERAPY: ibrutinib
420 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Grade 2 and greater bleeding events have occurred in patients on ibrutinib. Consider the benefit vs. risk of ibrutinib in patients
requiring anti-platelet or anticoagulant therapies.
Note to All Staff (2)
Upon initiation of ibrutinib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of ibrutinib treatment and may persist for
several weeks on treatment.
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+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 12 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or AST greater
than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ibrutinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Total LD.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:38:54 PM Page 13 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org