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CSC Hem Inpt ATG (Horse) For Aplastic Anemia Ver 9-6-17 (HL 3601)

CSC Hem Inpt ATG (Horse) For Aplastic Anemia Ver 9-6-17 (HL 3601) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM INPT ATG (HORSE) FOR APLASTIC ANEMIA VER: 9-6-17 –  Properties
Cycle 1 –  9/6/2017 through 10/3/2017 (28 days), Planned
Day 1 through 4, Cycle 1 –  Planned for 9/6/2017
Treatment Plan Information
Reference Information (1)
APLASTIC ANEMIA: Rosenfeld S, et al. Blood. 1995;85(11):3058-65.
Reference Information (2)
APLASTIC ANEMIA: Scheinberg P, et al. N Engl J Med 2011;365(5):430-8.
Treatment Plan Summary
DISEASE: Aplastic Anemia; THERAPY: antithymocyte globulin (HORSE) 40 mg/kg/day IV Day 1 through 4; CYCLE
LENGTH: 4 days; COURSE: 1 cycle
Consent
Verify Consent
Verify informed consent has been obtained.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to anti-thymocyte globulin can occur.
Monitoring Parameters (1)
Anti-thymocyte globulin: Monitor patient for serum sickness (rash, fever, malaise and polyarthralgias).
Vital Signs
SEE COMMENTS Starting when released Until Specified
Anti-thymocyte globulin: Monitor vital signs prior to infusion then every 30 minutes for the first hour then every 60
minutes until completion of infusion.
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.
Hydration
sodium chloride 0.9 % infusion
at 150 mL/hr, Intravenous, CONTINUOUS, For 106 hours Starting when released
Start hydration 4 hours prior to ATG and continue until 24 hours after last dose of ATG. Adjust hydration to keep total
IV fluid rate at 150 mL/hr.
Pre-Medications
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) injection 79.4 mg
79.4 mg (1 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 4 hours prior to ATG.
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Zztestonc,Edward E [2435061]
9/6/2017 12:40:36 PM Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 6 HOURS, 16 doses Starting when released
Give first dose 1 hour prior to ATG and continue until 12 hours after last dose of ATG.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, EVERY 6 HOURS, 16 doses Starting when released
Give first dose 1 hour prior to ATG and continue until 12 hours after last dose of ATG.
Emergency Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN, For 5 days Starting when released, ATG reaction
Indication = wheezing or urticaria
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, For 5 days Starting when released, ATG reaction, Administer over 1 Minutes
Indication = wheezing or urticaria
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, For 5 days Starting when released until S+5, ATG reaction, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, For 5 days Starting when released until S+5, dyspnea
Treatment Medications
antithymocyte globulin EQUINE (ATGAM) 3,176 mg in sodium chloride 0.9 % 1,000 mL bag
3,176 mg (40 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting when
released
Hypersensitivity risk. See emergency medications.
Infuse into central line (preferred) through 0.2 or 0.22 micron filter on Day 1 through 4. If infusion-related reaction
occurs, stop infusion and notify physician. Infusion may be restarted at reduced rate at physician discretion.
Round dose to the nearest 250 mg.
Note to All Staff (1)
Cyclosporine dose is reduced from original 6 mg/kg/dose to 2 mg/kg/dose due to drug-drug interaction with
posaconazole. If patient not taking posaconazole, re-assess cyclosporine dose as clinically appropriate.
cyclosporine modified (GENGRAF BRAND) cap 150 mg
150 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg Treatment plan recorded weight), Oral, 2 X DAILY (AT MEALTIME)
Starting when released
Start on Day 1. Adjust dose on Day 3 to achieve therapeutic level of 100 to 300 ng/mL.
Round dose to nearest 25 mg.
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) injection 39.7 mg
39.7 mg (0.5 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, EVERY 12 HOURS, 7 doses Starting when
released
Start 12 hours after 1 mg/kg dose. May increase dose to 1 mg/kg if infusion reaction to ATG occurs.
prednisone (DELTASONE) tab 39.5 mg
39.5 mg (rounded from 39.7 mg = 0.5 mg/kg × 79.4 kg Treatment plan recorded weight), Oral, 2 X DAILY (AT
MEALTIME), 14 doses Starting S+4 As Scheduled
Start on Day 5 and continue until no symptoms of serum sickness observed (minimum of 5-7 days). May increase dose
to 1 mg/kg if methylprednisolone dose was increased secondary to infusion reaction to ATG.
prednisone (DELTASONE) tab 40 mg
40 mg, Oral, 1 X DAILY, 3 doses Starting S+11 As Scheduled
Start predniSONE taper when no symptoms of serum sickness are observed.
prednisone (DELTASONE) tab 20 mg
20 mg, Oral, 1 X DAILY, 2 doses Starting S+14 As Scheduled
Indication = predniSONE taper
prednisone (DELTASONE) tab 10 mg
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Zztestonc,Edward E [2435061]
9/6/2017 12:40:36 PM Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

10 mg, Oral, 1 X DAILY, 2 doses Starting S+16 As Scheduled
Indication = predniSONE taper
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
Give until 2 months after completion of immunosuppressive therapy.
posaconazole (NOXAFIL) delayed release tab 300 mg
300 mg, Oral, 1 X DAILY Starting when released
Take with food. Swallow whole. Do not crush, chew, or divide tablet. Give until neutropenia resolves.
pentamidine (PENTAM) neb soln 300 mg
300 mg, Nebulization, ONCE, 1 dose Starting when released
Give until blood counts recover and then switch to sulfamethoxazole/trimethoprim.
Schedule pentamidine after discharge if necessary.
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Give until prednisone taper completed.
Take Home Medications
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take  by mouth 2 times daily Sat,Sun., Disp-16 tab, R-0, 2 X DAILY SAT, SUN starting S, Local Printer
Start per MD instruction after blood counts recover until 2 months after completion of immunosuppressive therapy.
Note to All Staff (1)
Assure patient has appointment scheduled for pentamidine administration if necessary.
Follow-Up
FOLLOW-UP
Follow-up per treating physician.
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Zztestonc,Edward E [2435061]
9/6/2017 12:40:36 PM Page 3 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org