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201605136

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

CSC HEM INPT CLADRIBINE(29D2-6) CYTARABINE(29D2-6) TBO-FILGRASTIM VER 10-9-15 (HL 5914)

CSC HEM INPT CLADRIBINE(29D2-6) CYTARABINE(29D2-6) TBO-FILGRASTIM VER 10-9-15 (HL 5914) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM INPT CLADRIBINE(29D:2-6)/CYTARABINE(29D:2-6)/TBO-FILGRASTIM VER:10-9-15 – Properties
Cycle 1 – 10/9/2015 through 11/6/2015 (29 days), Planned
Days 1 through 6 (Inpatient), Cycle 1 – Planned for 10/9/2015 through 10/14/2015
Treatment Plan Information
Reference Information (1)
ACUTE MYELOID LEUKEMIA: Robak T, et al. Leuk Lymphoma 2000;39(1-2):121-9.
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim
300 mcg subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000
mg/m2/day IV Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than 1.5 X ULN or AST
greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater than 1.5 X ULN .
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Zztestonc,Fiona F [2462287]
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with
neurochecks prior to each dose of cytarabine. Hold and notify MD for any concerns of toxicity.
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 24 HOURS, 5 doses Starting S+1 at 0000
Days 2 through 6: Administer 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 24 HOURS PRN, For 144 hours Starting S+1 at 0000,
nausea/vomiting
Days 2 through 6: Administer IV if unable to tolerate PO. Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 5 doses Starting S+1 at 0000
Days 2 through 6: Administer prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 144 hours Starting S+1 at 0000,
nausea/vomiting
Days 2 through 6: Administer IV if unable to tolerate PO. Administer prior to chemotherapy.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 24 doses Starting S+1 As Scheduled
Days 2 through 6: Administer first dose prior to cytarabine.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 24 HOURS, 5 doses Starting S+1 at 0000
Days 2 through 6: Administer prior to each dose of cytarabine.
Treatment Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe 300 mcg
300 mcg, Subcutaneous, 1 X DAILY (PM), 6 doses Starting when released
Days 1 through 6: Administer first dose 24 hours prior to first dose of cladribine.
Treatment Medications
cladribine (LEUSTATIN) 15.2 mg in sodium chloride 0.9 % 500 mL bag
15.2 mg (rounded from 15.15 mg = 5 mg/m2 × 3.03 m2 Treatment plan actual BSA),
Intravenous, EVERY 24 HOURS, 5 doses Starting S+1 at 0000
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Days 2 through 6: Administer over 120 minutes.
cytarabine PF (CYTOSAR) 6,060 mg in sodium chloride 0.9 % 250 mL bag
6,060 mg (2,000 mg/m2 × 3.03 m2 Treatment plan actual BSA), Intravenous, EVERY 24
HOURS, 5 doses Starting S+1 at 0000
Days 2 through 6: Begin after completion of cladribine infusion. Administer over 4 hours. Assess patient for signs of
cerebellar toxicity (incoordination, slurred speech) with neuro checks prior to each dose of cytarabine. Hold and notify
MD for any concerns of toxicity.
Supportive Care Medications
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 7 doses Starting when released
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
posaconazole DELAYED RELEASE (NOXAFIL EC) EC tab 300 mg
300 mg, Oral, 1 X DAILY Starting when released
Take with food. Swallow whole. Do not crush, chew, or divide tablet.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Total of 24 mg ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting
Total of 24 mg ondansetron per 24 hours (scheduled and PRN)
Take Home Medications (delete all that do not apply)
prednisolone (PRED FORTE) 1 % ophthalmic susp
1 drop in each eye 4 times daily. Use on Days 2 through 7., Disp-1 Bottle, R-0, 4 X DAILY
starting S
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take on Days 1 through 7., R-0, 1 X DAILY
starting S, Local Printer
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
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
posaconazole DELAYED RELEASE (NOXAFIL EC) 100 MG EC tab
Take 3 tabs by mouth one time daily., Disp-90 tab, R-5, 1 X DAILY starting S, Local
Printer
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Zztestonc,Fiona F [2462287]
10/9/2015 3:54:31 PM Page 3 of 7
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Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 11 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 18 FOLLOW-UP
LABS: CBC with DIFF.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 25 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
LABS: CBC with DIFF.
Lab Only - Day 8, Cycle 1 – Planned for 10/16/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim 300 mcg
subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000 mg/m2/day IV
Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 1 – Planned for 10/19/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim 300 mcg
subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000 mg/m2/day IV
Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
IV Access
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Zztestonc,Fiona F [2462287]
10/9/2015 3:54:31 PM Page 4 of 7
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Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 10/23/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim 300 mcg
subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000 mg/m2/day IV
Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 1 – Planned for 10/26/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim 300 mcg
subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000 mg/m2/day IV
Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
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Zztestonc,Fiona F [2462287]
10/9/2015 3:54:31 PM Page 5 of 7
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Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 – Planned for 10/30/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim 300 mcg
subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000 mg/m2/day IV
Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 25, Cycle 1 – Planned for 11/2/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim 300 mcg
subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000 mg/m2/day IV
Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
10/9/2015 3:54:31 PM Page 6 of 7
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Lab Only - Day 29, Cycle 1 – Planned for 11/6/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myeloid Leukemia (Relapsed/Refractory); THERAPY: TBO-filgrastim 300 mcg
subcutaneous once daily Days 1 through 6, cladribine 5 mg/m2/day IV Days 2 through 6, cytarabine 2000 mg/m2/day IV
Days 2 through 6; CYCLE LENGTH: 29 days; COURSE: 1 to 2 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Sign Actions
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Zztestonc,Fiona F [2462287]
10/9/2015 3:54:31 PM Page 7 of 7
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