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UWHC,UWMF,

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

CSC Hem Decitabine(42D1-3) Ver 11-23-15 (HL 1760)

CSC Hem Decitabine(42D1-3) Ver 11-23-15 (HL 1760) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM DECITABINE(42D:1-3) VER: 11-23-15 – Properties
Cycle 1 – 12/1/2015 through 1/11/2016 (42 days), Planned
Days 1 through 3, Cycle 1 – Planned for 12/1/2015
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Kantarjian HM, et al. Cancer 2006;106(8):1794-803
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Lubbert M, et al. J Clin Oncol 2011;29(15):1987-96
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous
Leukemia, Myelodysplastic Syndrome; THERAPY: decitabine 15 mg/m2/dose IV every 8 hours Day 1 through 3 (for a
total of 9 doses) ; CYCLE LENGTH: 42 days; COURSE: minimum of 3 cycles to determine response, ongoing treatment
as tolerated after 6 cycles.
Note to End-User
Protocol built for one cycle only. If a second cycle is intended, copy cycle 1 and paste it into the
treatment plan as the second cycle with the desired start date.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL
or Creatinine greater than or equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than
or equal to 2 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
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Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Treatment Medications
decitabine 31.4 mg in sodium chloride 0.9 % 100 mL bag
31.4 mg (rounded from 31.35 mg = 15 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
EVERY 8 HOURS, 9 doses Starting when released
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
for 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF
DAY 11 FOLLOW-UP
LABS: CBC with DIFF
DAY 15 FOLLOW-UP
LABS: CBC with DIFF
DAY 18 FOLLOW-UP
LABS: CBC with DIFF
DAY 22 FOLLOW-UP
LABS: CBC with DIFF
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DAY 25 FOLLOW-UP
LABS: CBC with DIFF
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments: RETURN TO CLINIC for appointment with provider; LABS: CBC with
DIFF, Creatinine, Total Bilirubin, ALT; ADMIT TO B6/6 through clinic for Cycle ___ of decitabine.
Lab Only - Day 8, Cycle 1 – Planned for 12/8/2015
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Kantarjian HM, et al. Cancer 2006;106(8):1794-803
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Lubbert M, et al. J Clin Oncol 2011;29(15):1987-96
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous
Leukemia, Myelodysplastic Syndrome; THERAPY: decitabine 15 mg/m2/dose IV every 8 hours Day 1 through 3 (for a
total of 9 doses) ; CYCLE LENGTH: 42 days; COURSE: minimum of 3 cycles to determine response, ongoing treatment
as tolerated after 6 cycles.
Note to End-User
Protocol built for one cycle only. If a second cycle is intended, copy cycle 1 and paste it into the treatment
plan as the second cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 1 – Planned for 12/11/2015
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Kantarjian HM, et al. Cancer 2006;106(8):1794-803
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Lubbert M, et al. J Clin Oncol 2011;29(15):1987-96
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous
Leukemia, Myelodysplastic Syndrome; THERAPY: decitabine 15 mg/m2/dose IV every 8 hours Day 1 through 3 (for a
total of 9 doses) ; CYCLE LENGTH: 42 days; COURSE: minimum of 3 cycles to determine response, ongoing treatment
as tolerated after 6 cycles.
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Note to End-User
Protocol built for one cycle only. If a second cycle is intended, copy cycle 1 and paste it into the treatment
plan as the second cycle with the desired start date.
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+10 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 12/15/2015
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Kantarjian HM, et al. Cancer 2006;106(8):1794-803
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Lubbert M, et al. J Clin Oncol 2011;29(15):1987-96
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous
Leukemia, Myelodysplastic Syndrome; THERAPY: decitabine 15 mg/m2/dose IV every 8 hours Day 1 through 3 (for a
total of 9 doses) ; CYCLE LENGTH: 42 days; COURSE: minimum of 3 cycles to determine response, ongoing treatment
as tolerated after 6 cycles.
Note to End-User
Protocol built for one cycle only. If a second cycle is intended, copy cycle 1 and paste it into the treatment
plan as the second cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,PedsBeiber [2668824]
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Lab Only - Day 18, Cycle 1 – Planned for 12/18/2015
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Kantarjian HM, et al. Cancer 2006;106(8):1794-803
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Lubbert M, et al. J Clin Oncol 2011;29(15):1987-96
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous
Leukemia, Myelodysplastic Syndrome; THERAPY: decitabine 15 mg/m2/dose IV every 8 hours Day 1 through 3 (for a
total of 9 doses) ; CYCLE LENGTH: 42 days; COURSE: minimum of 3 cycles to determine response, ongoing treatment
as tolerated after 6 cycles.
Note to End-User
Protocol built for one cycle only. If a second cycle is intended, copy cycle 1 and paste it into the treatment
plan as the second cycle with the desired start date.
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+17 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 - Days 22, Cycle 1 – Planned for 12/22/2015
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Kantarjian HM, et al. Cancer 2006;106(8):1794-803
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Lubbert M, et al. J Clin Oncol 2011;29(15):1987-96
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous
Leukemia, Myelodysplastic Syndrome; THERAPY: decitabine 15 mg/m2/dose IV every 8 hours Day 1 through 3 (for a
total of 9 doses) ; CYCLE LENGTH: 42 days; COURSE: minimum of 3 cycles to determine response, ongoing treatment
as tolerated after 6 cycles.
Note to End-User
Protocol built for one cycle only. If a second cycle is intended, copy cycle 1 and paste it into the treatment
plan as the second cycle with the desired start date.
IV Access
Insert and Maintain Peripheral IV
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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+21 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 25, Cycle 1 – Planned for 12/25/2015
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Kantarjian HM, et al. Cancer 2006;106(8):1794-803
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Lubbert M, et al. J Clin Oncol 2011;29(15):1987-96
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous
Leukemia, Myelodysplastic Syndrome; THERAPY: decitabine 15 mg/m2/dose IV every 8 hours Day 1 through 3 (for a
total of 9 doses) ; CYCLE LENGTH: 42 days; COURSE: minimum of 3 cycles to determine response, ongoing treatment
as tolerated after 6 cycles.
Note to End-User
Protocol built for one cycle only. If a second cycle is intended, copy cycle 1 and paste it into the treatment
plan as the second cycle with the desired start date.
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+24 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison