/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-96815-en.cckm

201611327

page

100

UWHC,UWMF,

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

CSC HEM Nilotinib(28D:1-28) VER 10-3-16 (HL 1889)

CSC HEM Nilotinib(28D:1-28) VER 10-3-16 (HL 1889) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM NILOTINIB(28D:1-28) VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Note to All Staff (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or long QT syndrome
as sudden death has been reported in these patients. Correct hypokalemia and hypomagnesemia prior to initiation of therapy and
monitor electrolytes periodically. ECGs are recommended to monitor the QTc at baseline, 7 days after initiation, periodically as
clinically indicated, and following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use
of QT-prolonging agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
Verify ECG obtained.
Cycle 1 – 11/22/2016 through 12/19/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 1 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Note to All Staff (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or long QT syndrome
as sudden death has been reported in these patients. Correct hypokalemia and hypomagnesemia prior to initiation of therapy and
monitor electrolytes periodically. ECGs are recommended to monitor the QTc at baseline, 7 days after initiation, periodically as
clinically indicated, and following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use
of QT-prolonging agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
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, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Potassium less than 3.5
mmol/L or Magnesium less than 1.7 mg/dL or Total Bilirubin greater than 4 mg/dL or AST or ALT greater than 2.5 X ULN or Amylase
greater than 2.5 X ULN or Lipase 2.5 X ULN.
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Remind patient that nilotinib needs an acidic stomach environment for absorption.
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): nilotinib (dispensed on Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 2 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
nilotinib (TASIGNA) 150 MG cap
Take by mouth 2 times daily. Swallow whole. Take on empty stomach. Avoid grapefruit products. Take *** mg in AM and *** mg
in PM., R-0, 2 X DAILY starting S
Dispense quantity in multiples of 28 capsules.
nilotinib (TASIGNA) 200 MG cap
Take by mouth 2 times daily. Swallow whole. Take on empty stomach. Avoid grapefruit products. Take *** mg in AM and *** mg
in PM., R-0, 2 X DAILY starting S
Dispense quantity in multiples of 28 capsules.
Follow-Up
DAY 7 FOLLOW-UP
RETURN TO CLINIC: appointment for ECG
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Potassium, Magnesium, Total
Bilirubin, AST, ALT, Alkaline Phosphatase
ECG Only - Day 7, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Note to All Staff (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or long QT syndrome
as sudden death has been reported in these patients. Correct hypokalemia and hypomagnesemia prior to initiation of therapy and
monitor electrolytes periodically. ECGs are recommended to monitor the QTc at baseline, 7 days after initiation, periodically as
clinically indicated, and following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use
of QT-prolonging agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
Treatment Conditions
Treatment Condition A
Verify ECG obtained.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/20/2016 through 1/16/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 3 of 10
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 (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or
long QT syndrome as sudden death has been reported in these patients. Correct hypokalemia and
hypomagnesemia prior to initiation of therapy and monitor electrolytes periodically. ECGs are recommended to
monitor the QTc at baseline, 7 days after initiation, periodically as clinically indicated, and following dose
adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use of QT-prolonging
agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
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
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Potassium less than 3.5
mmol/L or Magnesium less than 1.7 mg/dL or Total Bilirubin greater than 4 mg/dL or AST or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Remind patient that nilotinib needs an acidic stomach environment for absorption.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 4 of 10
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, nilotinib 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, Potassium, Magnesium, Total
Bilirubin, AST, ALT, Alkaline Phosphatase
Cycle 3 – 1/17/2017 through 2/13/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Note to All Staff (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or long QT syndrome
as sudden death has been reported in these patients. Correct hypokalemia and hypomagnesemia prior to initiation of therapy and
monitor electrolytes periodically. ECGs are recommended to monitor the QTc at baseline, 7 days after initiation, periodically as
clinically indicated, and following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use
of QT-prolonging agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
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
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 5 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Potassium less than 3.5
mmol/L or Magnesium less than 1.7 mg/dL or Total Bilirubin greater than 4 mg/dL or AST or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Remind patient that nilotinib needs an acidic stomach environment for absorption.
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, nilotinib 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, Potassium, Magnesium, Total
Bilirubin, AST, ALT, Alkaline Phosphatase
Cycle 4 – 2/14/2017 through 5/8/2017 (84 days), Planned
Day 1, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Note to All Staff (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or long QT syndrome
as sudden death has been reported in these patients. Correct hypokalemia and hypomagnesemia prior to initiation of therapy and
monitor electrolytes periodically. ECGs are recommended to monitor the QTc at baseline, 7 days after initiation, periodically as
clinically indicated, and following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use
of QT-prolonging agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
Consent
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 6 of 10
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
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Potassium less than 3.5
mmol/L or Magnesium less than 1.7 mg/dL or Total Bilirubin greater than 4 mg/dL or AST or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Remind patient that nilotinib needs an acidic stomach environment for absorption.
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, nilotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 85 FOLLOW-UP
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 7 of 10
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, Potassium, Magnesium, Total
Bilirubin, AST, ALT, Alkaline Phosphatase
Cycle 5 – 5/9/2017 through 7/31/2017 (84 days), Planned
Day 1, Cycle 5 – Planned for 5/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Note to All Staff (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or long QT syndrome
as sudden death has been reported in these patients. Correct hypokalemia and hypomagnesemia prior to initiation of therapy and
monitor electrolytes periodically. ECGs are recommended to monitor the QTc at baseline, 7 days after initiation, periodically as
clinically indicated, and following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use
of QT-prolonging agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
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
POTASSIUM
Expected-S+84 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
Treatment Parameters
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 8 of 10
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 or Platelets less than 75K/µL or Potassium less than 3.5
mmol/L or Magnesium less than 1.7 mg/dL or Total Bilirubin greater than 4 mg/dL or AST or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Remind patient that nilotinib needs an acidic stomach environment for absorption.
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, nilotinib 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, Potassium, Magnesium, Total
Bilirubin, AST, ALT, Alkaline Phosphatase
Cycle 6 – 8/1/2017 through 10/23/2017 (84 days), Planned
Day 1, Cycle 6 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Myelogenous Leukemia (Chronic Phase); THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH:
28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 300 mg by mouth twice daily; CYCLE LENGTH: 84 days; COURSE:
until disease progression.
Treatment Plan Summary (2)
DISEASE: Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute Lymphoblastic Leukemia; THERAPY:
nilotinib 400 mg by mouth twice daily; CYCLE LENGTH: 28 days; COURSE: 3 cycles followed by THERAPY: nilotinib 400 mg by
mouth twice daily; CYCLE LENGTH: 84 days; COURSE: until disease progression.
Note to All Staff (1)
Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia, hypomagnesemia or long QT syndrome
as sudden death has been reported in these patients. Correct hypokalemia and hypomagnesemia prior to initiation of therapy and
monitor electrolytes periodically. ECGs are recommended to monitor the QTc at baseline, 7 days after initiation, periodically as
clinically indicated, and following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use
of QT-prolonging agents and strong CYP3A4 inhibitors.
Note to All Staff (2)
Nilotinib needs an acidic stomach environment for absorption.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 9 of 10
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+84 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+84 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Potassium less than 3.5
mmol/L or Magnesium less than 1.7 mg/dL or Total Bilirubin greater than 4 mg/dL or AST or ALT greater than 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Remind patient that nilotinib needs an acidic stomach environment for absorption.
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, nilotinib 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, Potassium, Magnesium, Total
Bilirubin, AST, ALT, Alkaline Phosphatase
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:22:20 PM Page 10 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org