/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-121114-en.cckm

201709268

page

100

UWHC,UWMF,

Tools,

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

CSC HEM Obinutuzumab(56D:1) Maintenance Ver 9-25-17 (HL 6399)

CSC HEM Obinutuzumab(56D:1) Maintenance Ver 9-25-17 (HL 6399) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM OBINUTUZUMAB (56D:1) MAINTENANCE VER: 9-25-17 – Properties
Pre-Cycle – 9/18/2017 through 9/24/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 9/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Maintenance; THERAPY: obinutuzumab 1000 mg IV Day 1;
CYCLE LENGTH: 56 days; COURSE: up to 12 cycles in absence of disease progression.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
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-5, 2 X DAILY 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
prochlorperazine (COMPAZINE) 10 MG tab
Allergy/Contraindication: Promethazine Hcl Reactions: Vomiting
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
Cycle 1 – 9/25/2017 through 11/19/2017 (56 days), Planned
Day 1, Cycle 1 – Planned for 9/25/2017
Treatment Plan Information
Reference Information (1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Diane D [2466374]
9/25/2017 8:40:24 AM Page 1 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

RELAPSED/REFRACTORY NON-HODGKIN LYMPHOMA: Sehn LH, et al. Lancet Oncol 2016;17:1081-93.
Reference Information (2)
RELAPSED/REFRACTORY NON-HODGKIN LYMPHOMA: Fischer K, et al. J Clin Oncol. 2011;29(26):3559-66
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Maintenance; THERAPY: obinutuzumab 1000 mg IV Day 1;
CYCLE LENGTH: 56 days; COURSE: up to 12 cycles in absence of disease progression.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Diane D [2466374]
9/25/2017 8:40:24 AM Page 2 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC: for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, LDH; CHEMOTHERAPY ROOM APPOINTMENT: obinutuzumab for 270 minutes.
Lab Only - Day 15, Cycle 1 – Planned for 10/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Maintenance; THERAPY: obinutuzumab 1000 mg IV Day 1;
CYCLE LENGTH: 56 days; COURSE: up to 12 cycles in absence of disease progression.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Diane D [2466374]
9/25/2017 8:40:24 AM Page 3 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 11/20/2017 through 1/14/2018 (56 days), Planned
Day 1, Cycle 2 – Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Maintenance; THERAPY: obinutuzumab 1000 mg IV Day 1;
CYCLE LENGTH: 56 days; COURSE: up to 12 cycles in absence of disease progression.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
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+56 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+365, Routine
BUN
Expected-S+56 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+56 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Diane D [2466374]
9/25/2017 8:40:24 AM Page 4 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC: for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, LDH; CHEMOTHERAPY ROOM APPOINTMENT: obinutuzumab for 270 minutes.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Diane D [2466374]
9/25/2017 8:40:24 AM Page 5 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Lab Only - Day 15, Cycle 2 – Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Maintenance; THERAPY: obinutuzumab 1000 mg IV Day 1;
CYCLE LENGTH: 56 days; COURSE: up to 12 cycles in absence of disease progression.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/15/2018 through 3/11/2018 (56 days), Planned
Cycle 4 – 3/12/2018 through 5/6/2018 (56 days), Planned
Cycle 5 – 5/7/2018 through 7/1/2018 (56 days), Planned
Cycle 6 – 7/2/2018 through 8/26/2018 (56 days), Planned
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Diane D [2466374]
9/25/2017 8:40:24 AM Page 6 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org