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/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/name-96834-en.cckm

201611327

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100

UWHC,UWMF,

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

CSC HEM Outpt APML4 Maintenance VER 10-3-16 (HL 5289)

CSC HEM Outpt APML4 Maintenance VER 10-3-16 (HL 5289) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM OUTPT APML4 MAINTENANCE VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-11, 1 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/22/2016 through 2/19/2017 (90 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
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); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 1 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
Cycle 2 – 2/20/2017 through 5/20/2017 (90 days), Planned
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 2 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 2 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+90 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+90 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+90 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+90 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+90 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 3 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
Cycle 3 – 5/21/2017 through 8/18/2017 (90 days), Planned
Day 1, Cycle 3 – Planned for 5/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+90 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+90 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+90 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+90 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+90 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 4 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
Cycle 4 – 8/19/2017 through 11/16/2017 (90 days), Planned
Day 1, Cycle 4 – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 5 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+90 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+90 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+90 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+90 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+90 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 6 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
Cycle 5 – 11/17/2017 through 2/14/2018 (90 days), Planned
Day 1, Cycle 5 – Planned for 11/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+90 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+90 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+90 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+90 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+90 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 7 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
Cycle 6 – 2/15/2018 through 5/15/2018 (90 days), Planned
Day 1, Cycle 6 – Planned for 2/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 8 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+90 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+90 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+90 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+90 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+90 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 9 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
Cycle 7 – 5/16/2018 through 8/13/2018 (90 days), Planned
Day 1, Cycle 7 – Planned for 5/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+90 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+90 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+90 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+90 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+90 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 10 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
Cycle 8 – 8/14/2018 through 11/11/2018 (90 days), Planned
Day 1, Cycle 8 – Planned for 8/14/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); MAINTENANCE THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days
1 through 14, methotrexate 5 to 15 mg/m2 by mouth once weekly Days 15 to 90, mercaptopurine 50 to 90 mg/m2 by mouth daily
Days 15 to 90; CYCLE LENGTH: 90 days; COURSE: 8 cycles. Note (1): Maintenance begins 21 to 28 days (3 to 4 weeks) after the
end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+90 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 11 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CREATININE
Expected-S+90 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+90 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+90 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+90 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, Platelets, Creatinine, Total Bilirubin, AST, and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 3500/uL or Platelets less than 75K/uL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than 2.5 x ULN or
ALT greater than 2.5 x ULN.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medications: mercaptopurine, methotrexate and tretinoin
(dispensed on Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 14. *** mg in the AM and *** in the PM, R-0, starting S
Total daily dose = 45 mg/m2. Round dose up to the nearest 10 mg.
methotrexate 2.5 MG tab
Take *** mg by mouth once weekly on Days 15 through 90, R-0, starting S
Total WEEKLY dose = *** mg/m2
mercaptopurine (PURINETHOL) 50 MG tab
Take *** mg by mouth once daily on Days 15 through 90, R-0, starting S
Total DAILY dose = *** mg/m2
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
MULTIPLE DAY FOLLOW-UP (2)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 12 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 91 (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
ZZtestonc,Andrew [2428787]
11/22/2016 12:26:07 PM Page 13 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org