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201605136

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UWHC,UWMF,

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

CSC Hem Inpt/Outpt APML4 Induction Ver 11-23-15 (HL 5265)

CSC Hem Inpt/Outpt APML4 Induction Ver 11-23-15 (HL 5265) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM INPT/OUTPT APML4 INDUCTION VER: 11-23-15 – Properties
Cycle 1 – 12/2/2015 through 1/6/2016 (36 days), Planned
Day 1 through 8 Inpatient, Cycle 1 – Planned for 12/2/2015
Treatment Plan Information
Reference Information (1)
ACUTE PROMYELOCYTIC LEUKEMIA: Iland HJ, et al. Blood 2012;120(8):1570-80.
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by
Consolidation HL #5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment
duration should be extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to
28 days (3 to 4 weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
Note to All Staff (2)
Consider LP assessment at start of therapy.
Note to all Staff (3)
Anticoagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization
and then twice weekly thereafter.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
EVERY 24 HOURS Starting when released for 7 days, Routine
PROTHROMBIN TIME/INR
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter.
D-DIMER, QUANT
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter.
PTT
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter.
FIBRINOGEN
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter.
GLUCOSE
EVERY MONDAY AND FRIDAY Starting when released for 7 days
POTASSIUM
EVERY MONDAY AND FRIDAY Starting S As Scheduled for 7 days
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SODIUM
EVERY MONDAY AND FRIDAY Starting S As Scheduled for 7 days
BUN
EVERY MONDAY AND FRIDAY Starting when released for 7 days
CREATININE
EVERY MONDAY AND FRIDAY Starting when released for 7 days
URIC ACID
EVERY MONDAY AND FRIDAY Starting when released for 7 days
BILIRUBIN, TOTAL
EVERY MONDAY AND FRIDAY Starting when released for 7 days
AST/SGOT
EVERY MONDAY AND FRIDAY Starting when released for 7 days
ALT/SGPT
EVERY MONDAY AND FRIDAY Starting when released for 7 days
ALKALINE PHOSPHATASE
EVERY MONDAY AND FRIDAY Starting when released for 7 days
LD, TOTAL
EVERY MONDAY AND FRIDAY Starting when released for 7 days
CALCIUM
EVERY MONDAY AND FRIDAY Starting when released for 7 days
PHOSPHATE
EVERY MONDAY AND FRIDAY Starting when released for 7 days
MAGNESIUM
EVERY MONDAY AND FRIDAY Starting when released for 7 days
PROTEIN, TOTAL
EVERY MONDAY AND FRIDAY Starting when released for 7 days
CHOLESTEROL
EVERY MONDAY AND FRIDAY Starting when released for 7 days
TRIGLYCERIDE
EVERY MONDAY AND FRIDAY Starting when released for 7 days
CBC WITH DIFFERENTIAL
NEXT AM Starting S+7 As Scheduled for 1 occurrence
GLUCOSE
NEXT AM Starting S+7 As Scheduled for 1 occurrence
POTASSIUM
NEXT AM Starting S+7 As Scheduled for 1 occurrence
SODIUM
NEXT AM Starting S+7 As Scheduled for 1 occurrence
BUN
NEXT AM Starting S+7 As Scheduled for 1 occurrence
CREATININE
NEXT AM Starting S+7 As Scheduled for 1 occurrence
URIC ACID
NEXT AM Starting S+7 As Scheduled for 1 occurrence
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BILIRUBIN, TOTAL
NEXT AM Starting S+7 As Scheduled for 1 occurrence
AST/SGOT
NEXT AM Starting S+7 As Scheduled for 1 occurrence
ALT/SGPT
NEXT AM Starting S+7 As Scheduled for 1 occurrence
ALKALINE PHOSPHATASE
NEXT AM Starting S+7 As Scheduled for 1 occurrence
LD, TOTAL
NEXT AM Starting S+7 As Scheduled for 1 occurrence
CALCIUM
NEXT AM Starting S+7 As Scheduled for 1 occurrence
PHOSPHATE
NEXT AM Starting S+7 As Scheduled for 1 occurrence
MAGNESIUM
NEXT AM Starting S+7 As Scheduled for 1 occurrence
PROTEIN, TOTAL
NEXT AM Starting S+7 As Scheduled for 1 occurrence
CHOLESTEROL
NEXT AM Starting S+7 As Scheduled for 1 occurrence
TRIGLYCERIDE
NEXT AM Starting S+7 As Scheduled for 1 occurrence
PROTHROMBIN TIME/INR
NEXT AM Starting S+7 As Scheduled for 1 occurrence
Draw daily until normalization and then twice weekly thereafter.
D-DIMER, QUANT
NEXT AM Starting S+7 As Scheduled for 1 occurrence
Draw daily until normalization and then twice weekly thereafter.
PTT
NEXT AM Starting S+7 As Scheduled for 1 occurrence
Draw daily until normalization and then twice weekly thereafter.
FIBRINOGEN
NEXT AM Starting S+7 As Scheduled for 1 occurrence
Draw daily until normalization and then twice weekly thereafter.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, Creatinine, PT/INR, and
Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/uL or Total Bilirubin greater than 2
mg/dL or Creatinine greater than 2 mg/dL. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as
appropriately with fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
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Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 48 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 48 HOURS PRN, For 9 days Starting S+1 at 0000 until S+10,
nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Treatment Medications
tretinoin (VESANOID) cap 50 mg
50 mg (rounded from 47.025 mg = 22.5 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY
(AT MEALTIME) Starting when released
idarubicin (IDAMYCIN) injection
Intravenous, EVERY 48 HOURS, 4 doses Starting S+1 at 0000, for 5-10 Minutes
Give through running IV line. See Dose Modifications in Treatment Plan Information. For patients 1 through 60 years of
age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients 61 through 70 years of age: starting dose of
idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age: starting dose of idarubicin is 6 mg/m2 IV per
day.
prednisone (DELTASONE) tab 92 mg
92 mg (1 mg/kg × 92 kg Treatment plan actual weight), Oral, 1 X DAILY Starting when released
Days 1 through 10, or until WBC count falls below 10K/uL for differentiation syndrome prophylaxis.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): tretinoin and
prednisone (dispensed on day of discharge).
Supportive Care Medications
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 7 doses Starting when released
Supportive Care Medications (delete all that do not apply)
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acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days *** through 36 of Induction Cycle. *** mg in the AM and *** mg in the PM, R-0, starting
S, Local Printer
Total daily dose = 45 mg/m2. Round up to the nearest 10 mg.
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
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., Disp-60 tab, R-5, 1 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed (For nausea)., Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take *** tabs by mouth daily on Days *** through *** of Induction. Total daily dose = ***, R-0, starting
S, Local Printer
prednisone (DELTASONE) 10 MG tab
Take *** tabs by mouth daily on Days *** through *** of Induction. Total daily dose = ***, starting S,
Local Printer
prednisone (DELTASONE) 5 MG tab
Take *** tabs by mouth daily on Days *** through *** of Induction. Total daily dose = ***, R-0, starting
S
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
RETURN TO CLINIC for appointment with provider Days 8, 15, 22, 29 and 36. CHEMOTHERAPY
ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes. Days 9 through 36.
MULTIPLE DAY FOLLOW-UP (2)
LABS: Three times weekly (Monday, Wednesday and Friday): CBC with DIFF. LABS: Twice weekly
(Monday and Friday): INR/PT, aPTT, Fibrinogen and D-dimer. LABS: Twice weekly (Monday and Friday) for first three
weeks of induction, then once weekly (Monday) thereafter: Glucose, BUN, Creatinine, Uric Acid, Total Bilirubin, AST,
ALT, Alkaline Phosphatase, LDH, Sodium, Potassium, Calcium, Phosphate, Magnesium, Total Protein, Cholesterol and
Triglycerides.
MULTIPLE DAY FOLLOW-UP (3)
RETURN TO CLINIC for appointment with provider Cycle 1 Day 1 of Consolidation cycle (3 to 4 weeks
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after the end of Induction).
Day 9, Cycle 1 – Planned for 12/10/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 10, Cycle 1 – Planned for 12/11/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
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Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater
than 2 mg/dL or QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as
appropriately with fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 11, Cycle 1 – Planned for 12/12/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
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HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
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Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 12, Cycle 1 – Planned for 12/13/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 10 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 13, Cycle 1 – Planned for 12/14/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 11 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 12 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 14, Cycle 1 – Planned for 12/15/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 13 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 15, Cycle 1 – Planned for 12/16/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 14 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 16, Cycle 1 – Planned for 12/17/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 15 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 16 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 17, Cycle 1 – Planned for 12/18/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 17 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 18, Cycle 1 – Planned for 12/19/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 18 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 19 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 19, Cycle 1 – Planned for 12/20/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 20 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 20, Cycle 1 – Planned for 12/21/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 21 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 21, Cycle 1 – Planned for 12/22/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 22 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 23 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 22, Cycle 1 – Planned for 12/23/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 24 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 23, Cycle 1 – Planned for 12/24/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 25 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 26 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 24, Cycle 1 – Planned for 12/25/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 27 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 25, Cycle 1 – Planned for 12/26/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 28 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 26, Cycle 1 – Planned for 12/27/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 29 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 30 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 27, Cycle 1 – Planned for 12/28/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 31 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 28, Cycle 1 – Planned for 12/29/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 32 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 33 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 29, Cycle 1 – Planned for 12/30/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 34 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 30, Cycle 1 – Planned for 12/31/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 35 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 31, Cycle 1 – Planned for 1/1/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 36 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 37 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 32, Cycle 1 – Planned for 1/2/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 38 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 33, Cycle 1 – Planned for 1/3/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 39 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 40 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 34, Cycle 1 – Planned for 1/4/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 41 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 35, Cycle 1 – Planned for 1/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 42 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
Day 36, Cycle 1 – Planned for 1/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); INDUCTION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 36, idarubicin 6 to 12 mg/m2 IV Days 2, 4, 6 and 8, arsenic trioxide 0.15
mg/kg IV daily Days 9 through 36, prednisone 1 mg/kg by mouth daily Days 1 through 10 or until WBC count falls below
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 43 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

10K/uL for differentiation syndrome prophylaxis; CYCLE LENGTH: 36 days; COURSE: 1 cycle followed by Consolidation
HL# 5287. Note (1): When tretinoin or arsenic trioxide is omitted for 3 or more days, the treatment duration should be
extended beyond Day 36 to compensate for the omitted doses. Note (2): Consolidation begins 21 to 28 days (3 to 4
weeks) after the end of Induction.
Dose Modifications
For patients 1 through 60 years of age: starting dose of idarubicin is 12 mg/m2 IV per day. For patients
61 through 70 years of age: starting dose of idarubicin is 9 mg/m2 IV per day. For patients greater than 70 years of age:
starting dose of idarubicin is 6 mg/m2 IV per day.
Note to All Staff (1)
Labs will be ordered outside of treatment plan beginning on Day 9 (outpatient).
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 TWICE WEEKLY for the first 3 weeks and then WEEKLY that pretreatment labs have been
obtained: Potassium, Magnesium, Total Bilirubin, Creatinine, CBC with DIFF, PT/INR, and Fibrinogen.
Treatment Parameters
Hold and notify authorizing prescriber WEEKLY for: Platelets less than 30K/uL or Potassium less than 4
mmol/L or Magnesium less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or
QTc greater than 500 msec. If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with
fresh frozen plasma and/ or cryoprecipitate.
Treatment Condition A
Verify ECG obtained twice weekly until CR.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 44 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 13.8 mg in sodium chloride 0.9 % 250 mL bag
13.8 mg (0.15 mg/kg × 92 kg Treatment plan actual weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes. Days 9 through 36.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on day of discharge.
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:57:27 AM Page 45 of 45
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison