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CSC Hem BFM Phase 3 (Interim Maintenance) VER 10-3-16 (HL 3226)

CSC Hem BFM Phase 3 (Interim Maintenance) VER 10-3-16 (HL 3226) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM BFM PHASE 3 (INTERIM MAINTENANCE) VER: 10-3-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INTERIM MAINTENANCE: Begin Day 71 from start of induction; THERAPY:
mercaptopurine 60 mg/m2 PO Day 1 through 42; methotrexate 15 mg/m2 PO Day 1, 8, 15, 22, 29 and 36; imatinib 400 to 600 mg
PO daily (for Philadelphia chromosome positive disease); CYCLE LENGTH: 42 days; COURSE: 1 cycle
Consent
Verify Consent
Verify informed consent has been obtained.
Take Home Medications (delete all that do not apply)
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 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-11, 1 X DAILY starting S, Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/15/2016 through 12/26/2016 (42 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P et al. J Clin Oncol. 1993; 11(11): 2234-42.
Reference Information (2)
See BFM Schedule of Assessments [3549] for lab orders.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INTERIM MAINTENANCE: Begin Day 71 from start of induction; THERAPY:
mercaptopurine 60 mg/m2 PO Day 1 through 42; methotrexate 15 mg/m2 PO Day 1, 8, 15, 22, 29 and 36; imatinib 400 to 600 mg
PO daily (for Philadelphia chromosome positive disease); CYCLE LENGTH: 42 days; COURSE: 1 cycle
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: ANC, Platelets, Total Bilirubin, AST, ALT
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/15/2016 3:28:59 PM Page 1 of 2
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine greater than 1.5
mg/dL or Creatinine Clearance less than 60 mL/min, Total Bilirubin greater than 3 mg/dL or AST or ALT greater than or equal to 2.5
X 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 10 UNIT/ML lock flush 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): mercaptopurine, methotrexate, imatinib (for
Philadelphia chromosome positive disease)
Take Home Medications
mercaptopurine (PURINETHOL) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Day 1 through 42., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
methotrexate 2.5 MG tab
Take 10.5 tabs by mouth once weekly. Take on Day 1, 8, 15, 22, 29 and 36., 26.25 mg (rounded from 26.85 mg = 15 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S
Round dose up to the nearest 2.5 mg.
Take Home Medications (delete all that do not apply)
imatinib (GLEEVEC) 400 MG tab
Take by mouth one time daily. Total daily dose = *** mg., R-11, 1 X DAILY starting S, Local Printer
For Philadelphia chromosome positive disease
imatinib (GLEEVEC) 100 MG tab
Take by mouth one time daily. Total daily dose = *** mg., R-11, 1 X DAILY starting S, Local Printer
For Philadelphia chromosome positive disease
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day ***, *** and ***: LABS: {INTERIM MAINTENANCE LABS:19664}
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Potassium, Chloride,
Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Fibrinogen; CHEMOTHERAPY ROOM
APPOINTMENT: DOXOrubicin and vinCRIStine for 30 minutes
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ZZtestonc,Andrew [2428787]
11/15/2016 3:28:59 PM Page 2 of 2
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org