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

/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/name-96804-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Imatinib(28D:1-28) VER 10-3-16 (HL 1887)

CSC HEM Imatinib(28D:1-28) VER 10-3-16 (HL 1887) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM IMATINIB(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: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive); THERAPY: imatinib 600 mg by mouth daily (may
increase dose to imatinib 800 mg by mouth daily for disease progression or lack of response); CYCLE LENGTH: 28 days; COURSE:
3 cycles followed by THERAPY: imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response); CYCLE LENGTH: 84 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 28
days; COURSE: 3 cycles followed by THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 84 days; COURSE: until
disease progression.
Treatment Plan Summary (3)
DISEASE: Chronic Myelogenous Leukemia (Accelerated/Blast Phase); THERAPY: imatinib 600 mg by mouth once daily; CYCLE
LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: imatinib 600 mg by mouth once daily; CYCLE LENGTH: 84 days;
COURSE: until disease progression.
Treatment Plan Summary (4)
DISEASE: Hypereosinophilic Syndrome (HES); THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-
PDGFRalpha infusion kinase, the starting dose is imatinib 100 mg by mouth daily); CYCLE LENGTH: 28 days; COURSE: 3 cycles
followed by THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily); CYCLE LENGTH: 84 days; COURSE: Until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
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)
ACUTE LYMPHOBLASTIC LEUKEMIA: Ottmann O, et al. Cancer. 2007; 109(10):2068-76
Reference Information (2)
CHRONIC MYELOGENOUS LEUKEMIA: O'Brien, et al. N Engl J Med. 2003; 348(11):994-1004
Reference Information (3)
CHRONIC MYELOGENOUS LEUKEMIA: Druker B, et al. N Engl J Med. 2006; 355(23):2408-17
Reference Information (4)
HYPEREOSINOPHILIC SYNDROME: Baccarani M, et al. Haematologica. 2007; 92(9):1173-79
Reference Information (5)
HYPEREOSINOPHILIC SYNDROME: Cools J, et al. N Engl J Med. 2003; 348(13):1201-14
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive); THERAPY: imatinib 600 mg by mouth daily (may
increase dose to imatinib 800 mg by mouth daily for disease progression or lack of response); CYCLE LENGTH: 28 days; COURSE:
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 1 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

3 cycles followed by THERAPY: imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response); CYCLE LENGTH: 84 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 28
days; COURSE: 3 cycles followed by THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 84 days; COURSE: until
disease progression.
Treatment Plan Summary (3)
DISEASE: Chronic Myelogenous Leukemia (Accelerated/Blast Phase); THERAPY: imatinib 600 mg by mouth once daily; CYCLE
LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: imatinib 600 mg by mouth once daily; CYCLE LENGTH: 84 days;
COURSE: until disease progression.
Treatment Plan Summary (4)
DISEASE: Hypereosinophilic Syndrome (HES); THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-
PDGFRalpha infusion kinase, the starting dose is imatinib 100 mg by mouth daily); CYCLE LENGTH: 28 days; COURSE: 3 cycles
followed by THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily); CYCLE LENGTH: 84 days; COURSE: Until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min or Total Bilirubin greater than 4 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): imatinib (dispensed on Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications (delete all that do not apply)
imatinib (GLEEVEC) 100 MG tab
Take by mouth one time daily. No grapefruit products., R-0, 1 X DAILY starting S, Local Printer
imatinib (GLEEVEC) 400 MG tab
Take by mouth one time daily. No grapefruit products., R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 2 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin
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: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive); THERAPY: imatinib 600 mg by mouth daily (may
increase dose to imatinib 800 mg by mouth daily for disease progression or lack of response); CYCLE LENGTH: 28 days; COURSE:
3 cycles followed by THERAPY: imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response); CYCLE LENGTH: 84 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 28
days; COURSE: 3 cycles followed by THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 84 days; COURSE: until
disease progression.
Treatment Plan Summary (3)
DISEASE: Chronic Myelogenous Leukemia (Accelerated/Blast Phase); THERAPY: imatinib 600 mg by mouth once daily; CYCLE
LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: imatinib 600 mg by mouth once daily; CYCLE LENGTH: 84 days;
COURSE: until disease progression.
Treatment Plan Summary (4)
DISEASE: Hypereosinophilic Syndrome (HES); THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-
PDGFRalpha infusion kinase, the starting dose is imatinib 100 mg by mouth daily); CYCLE LENGTH: 28 days; COURSE: 3 cycles
followed by THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily); CYCLE LENGTH: 84 days; COURSE: Until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min or Total Bilirubin greater than 4 mg/dL.
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 3:12:07 PM Page 3 of 9
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, imatinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin
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: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive); THERAPY: imatinib 600 mg by mouth daily (may
increase dose to imatinib 800 mg by mouth daily for disease progression or lack of response); CYCLE LENGTH: 28 days; COURSE:
3 cycles followed by THERAPY: imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response); CYCLE LENGTH: 84 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 28
days; COURSE: 3 cycles followed by THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 84 days; COURSE: until
disease progression.
Treatment Plan Summary (3)
DISEASE: Chronic Myelogenous Leukemia (Accelerated/Blast Phase); THERAPY: imatinib 600 mg by mouth once daily; CYCLE
LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: imatinib 600 mg by mouth once daily; CYCLE LENGTH: 84 days;
COURSE: until disease progression.
Treatment Plan Summary (4)
DISEASE: Hypereosinophilic Syndrome (HES); THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-
PDGFRalpha infusion kinase, the starting dose is imatinib 100 mg by mouth daily); CYCLE LENGTH: 28 days; COURSE: 3 cycles
followed by THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily); CYCLE LENGTH: 84 days; COURSE: Until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 4 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min or Total Bilirubin greater than 4 mg/dL.
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, imatinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin
Cycle 4 – 2/13/2017 through 5/7/2017 (84 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive); THERAPY: imatinib 600 mg by mouth daily (may
increase dose to imatinib 800 mg by mouth daily for disease progression or lack of response); CYCLE LENGTH: 28 days; COURSE:
3 cycles followed by THERAPY: imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response); CYCLE LENGTH: 84 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 28
days; COURSE: 3 cycles followed by THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 84 days; COURSE: until
disease progression.
Treatment Plan Summary (3)
DISEASE: Chronic Myelogenous Leukemia (Accelerated/Blast Phase); THERAPY: imatinib 600 mg by mouth once daily; CYCLE
LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: imatinib 600 mg by mouth once daily; CYCLE LENGTH: 84 days;
COURSE: until disease progression.
Treatment Plan Summary (4)
DISEASE: Hypereosinophilic Syndrome (HES); THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-
PDGFRalpha infusion kinase, the starting dose is imatinib 100 mg by mouth daily); CYCLE LENGTH: 28 days; COURSE: 3 cycles
followed by THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily); CYCLE LENGTH: 84 days; COURSE: Until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 5 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min or Total Bilirubin greater than 4 mg/dL.
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, imatinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin
Cycle 5 – 5/8/2017 through 7/30/2017 (84 days), Planned
Day 1, Cycle 5 – Planned for 5/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive); THERAPY: imatinib 600 mg by mouth daily (may
increase dose to imatinib 800 mg by mouth daily for disease progression or lack of response); CYCLE LENGTH: 28 days; COURSE:
3 cycles followed by THERAPY: imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response); CYCLE LENGTH: 84 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 28
days; COURSE: 3 cycles followed by THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 84 days; COURSE: until
disease progression.
Treatment Plan Summary (3)
DISEASE: Chronic Myelogenous Leukemia (Accelerated/Blast Phase); THERAPY: imatinib 600 mg by mouth once daily; CYCLE
LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: imatinib 600 mg by mouth once daily; CYCLE LENGTH: 84 days;
COURSE: until disease progression.
Treatment Plan Summary (4)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 6 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Hypereosinophilic Syndrome (HES); THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-
PDGFRalpha infusion kinase, the starting dose is imatinib 100 mg by mouth daily); CYCLE LENGTH: 28 days; COURSE: 3 cycles
followed by THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily); CYCLE LENGTH: 84 days; COURSE: Until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min or Total Bilirubin greater than 4 mg/dL.
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, imatinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin
Cycle 6 – 7/31/2017 through 10/22/2017 (84 days), Planned
Day 1, Cycle 6 – Planned for 7/31/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 7 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive); THERAPY: imatinib 600 mg by mouth daily (may
increase dose to imatinib 800 mg by mouth daily for disease progression or lack of response); CYCLE LENGTH: 28 days; COURSE:
3 cycles followed by THERAPY: imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response); CYCLE LENGTH: 84 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 28
days; COURSE: 3 cycles followed by THERAPY: imatinib 400 mg by mouth daily; CYCLE LENGTH: 84 days; COURSE: until
disease progression.
Treatment Plan Summary (3)
DISEASE: Chronic Myelogenous Leukemia (Accelerated/Blast Phase); THERAPY: imatinib 600 mg by mouth once daily; CYCLE
LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: imatinib 600 mg by mouth once daily; CYCLE LENGTH: 84 days;
COURSE: until disease progression.
Treatment Plan Summary (4)
DISEASE: Hypereosinophilic Syndrome (HES); THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-
PDGFRalpha infusion kinase, the starting dose is imatinib 100 mg by mouth daily); CYCLE LENGTH: 28 days; COURSE: 3 cycles
followed by THERAPY: imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily); CYCLE LENGTH: 84 days; COURSE: Until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min or Total Bilirubin greater than 4 mg/dL.
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, imatinib will be ordered through the medication activity after the initial order.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 8 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin
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ZZtestonc,Andrew [2428787]
11/21/2016 3:12:07 PM Page 9 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org