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CSC HEM Bendamustine(28D:1,2)/Obinutuzumab(28D) INDUCTION VER 10-4-17 (HL 6398)

CSC HEM Bendamustine(28D:1,2)/Obinutuzumab(28D) INDUCTION VER 10-4-17 (HL 6398) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM BENDAMUSTINE(28D:1,2)/OBINUTUZUMAB(28D) INDUCTION VER: 10-4-17 –  Properties
Pre-Cycle –  9/27/2017 through 10/3/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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
URIC ACID
Expected: S Approximate, Expires: S+365, Routine
HEPATITIS B CORE AB, TOTAL
Expected: S Approximate, Expires: S+365, Routine
HEPATITIS B SURFACE AG
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 1 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth once daily for 7 days of Cycle 1. Start 1 day prior to 1st obinutuzumab dose., Disp-7 tab, R-0,
starting S, Local Printer
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
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tablet by mouth twice daily on Saturday and Sunday., Disp-16 tab, R-5, starting S
famotidine (PEPCID) 20 MG tab
Take 1 tab by mouth 2 times daily., 20 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab 2x daily on Day 3 and 4. May take 1 tab every 8h as needed for nausea on other days, Disp-30 tab, R-5,
starting S
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
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 300 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 –  10/4/2017 through 10/31/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 10/4/2017
Treatment Plan Information
Reference Information (1)
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: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
Note to All Staff (1)
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 2 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine 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
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 3 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Hydration (delete all that do not apply)
sodium chloride 0.9 % infusion
Intravenous, ONCE, 1 dose Starting when released
Infuse 250-500 mL over an hour.
For Tumor Lysis prophylaxis in patients with high disease burden.
Pre-Medications
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.
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.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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
Should be administered IV push over at least 2 minutes.
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
Administer at 50 mg/hr (15.8 mL/hr). The rate of infusion can be escalated in increments of 50 mg/hr (15.8 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.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: bendamustine for 60 minutes.
DAY 8 FOLLOW-UP
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 4 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium; CHEMOTHERAPY ROOM APPOINTMENT:
obinutuzumab for 270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium; CHEMOTHERAPY ROOM APPOINTMENT:
obinutuzumab for 270 minutes.
DAY 29 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 and bendamustine for 270
minutes.
Day 2, Cycle 1 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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+1 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+1 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+1 Approximate, Expires: S+365, Routine
BUN
Expected: S+1 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+1 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+1 Approximate, Expires: S+365, Routine
URIC ACID
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 5 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Expected: S+1 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+1 Approximate, Expires: S+365, Routine
Treatment Conditions
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 reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
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.
Hydration (delete all that do not apply)
sodium chloride 0.9 % infusion
Intravenous, ONCE, 1 dose Starting when released
Infuse 250-500 mL over an hour.
For Tumor Lysis prophylaxis in patients with high disease burden.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 6 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 –  Planned for 10/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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+6 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+6 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+6 Approximate, Expires: S+365, Routine
BUN
Expected: S+6 Approximate, Expires: S+365, Routine
CREATININE
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 7 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Expected: S+6 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+6 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
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
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 8 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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
Should be administered IV push over at least 2 minutes.
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
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 9 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+7 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
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.
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 10 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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
Should be administered IV push over at least 2 minutes.
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
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  11/1/2017 through 11/28/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 11/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 11 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@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+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+14 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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine 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
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 12 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy. OMIT if patient is receiving dexamethasone 20 mg IV to prevent obinutuzumab reaction.
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
Should be administered IV push over at least 2 minutes.
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.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 13 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 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 and bendamustine for 270
minutes.
Day 2, Cycle 2 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
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
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 14 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 –  Planned for 11/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
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.
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 15 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+13 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 –  11/29/2017 through 12/26/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 11/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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+27 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+27 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+27 Approximate, Expires: S+365, Routine
BUN
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+27 Approximate, Expires: S+365, Routine
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 16 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

LD, TOTAL
Expected: S+27 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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine 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
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy. OMIT if patient is receiving dexamethasone 20 mg IV to prevent obinutuzumab reaction.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 17 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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
Should be administered IV push over at least 2 minutes.
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.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 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 and bendamustine for 270
minutes.
Day 2, Cycle 3 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 18 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal
Necrolysis (TEN), some fatal, have been reported when bendamustine was administered concomitantly
with allopurinol and other medications known to cause these syndromes. Note: per protocol patients
at high risk for tumor lysis syndrome will receive allopurinol.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 19 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
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+13 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 4 –  12/27/2017 through 1/23/2018 (28 days), Planned
Cycle 5 –  1/24/2018 through 2/20/2018 (28 days), Planned
Cycle 6 –  2/21/2018 through 3/20/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 2/21/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 20 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
Note to all Staff (3)
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+27 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+27 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+27 Approximate, Expires: S+365, Routine
BUN
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+27 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+27 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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 21 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy. OMIT if patient is receiving dexamethasone 20 mg IV to prevent obinutuzumab reaction.
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
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 22 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
Per treating physician.
Day 2, Cycle 6 –  Planned for 2/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 23 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@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.
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 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 –  Planned for 3/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Non-Hodgkin Lymphoma; PHASE: Induction; THERAPY: obinutuzumab 1000 mg IV Day 1,
8, and 15, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
obinutuzumab 1000 mg IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 28 days; COURSE: 5 cycles
followed by Maintenance (see HL 6399: CSC HEM OBINUTUZUMAB(56D:1) MAINTENANCE).
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ZZtestonc,Beth B [2468878]
10/4/2017 2:12:27 PM Page 24 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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)
Monitor patients for skin reactions. Cases of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Note: per protocol patients at high risk for tumor lysis syndrome will
receive allopurinol.
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+13 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,Beth B [2468878]
10/4/2017 2:12:27 PM Page 25 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org