/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-96849-en.cckm

201611327

page

100

UWHC,UWMF,

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

CSC HEM Ruxolitinib(28D:1-28) VER 10-3-16 (HL 4863)

CSC HEM Ruxolitinib(28D:1-28) VER 10-3-16 (HL 4863) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM RUXOLITINIB(28D:1-28) VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
Cycle 1 – 11/22/2016 through 12/19/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
MYELOFIBROSIS: Verstovsek S., et al. N Eng J Med. 2012;366(9):799-807.
Reference Information (2)
MYELOFIBROSIS: Harrison CN., et al. J Clin Oncol 2011;29(15):(abstract LBA650).
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
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,Andrew [2428787]
11/22/2016 12:40:59 PM Page 1 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
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: Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Calculated Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than ULN.
Treatment Medications
See Take Home Medication(s)
Refer to take home medications section for the following treatment medication(s): ruxolitinib (dispensed on Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications (delete all that do not apply)
ruxolitinib phosphate (JAKAFI) 5 MG tab
Take 1 tab by mouth 2 times daily., 5 mg, Disp-60 tab, R-0, 2 X DAILY starting S, Local Printer
Ruxolitinib Phosphate (JAKAFI) 10 MG tab
Take 1 tab by mouth 2 times daily., 10 mg, Disp-60 tab, R-0, 2 X DAILY starting S, Local Printer
Ruxolitinib Phosphate (JAKAFI) 15 MG tab
Take 1 tab by mouth 2 times daily., 15 mg, Disp-60 tab, R-0, 2 X DAILY starting S, Local Printer
Ruxolitinib Phosphate (JAKAFI) 20 MG tab
Take 1 tab by mouth 2 times daily., 20 mg, Disp-60 tab, R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with ANC (DIFF if to be done locally), BUN,
Creatinine, Total Bilirubin, AST, and ALT.
Lab Only - Day 15, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:40:59 PM Page 2 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
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 2 – 12/20/2016 through 1/16/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 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
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:40:59 PM Page 3 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Calculated Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ruxolitinib will be ordered through the medication activity after the initial order.
Follow-Up
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 ANC (DIFF if to be done locally), BUN,
Creatinine, Total bilirubin, AST, and ALT.
Lab Only - Day 15, Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
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 – 1/17/2017 through 2/13/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
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,Andrew [2428787]
11/22/2016 12:40:59 PM Page 4 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Calculated Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ruxolitinib will be ordered through the medication activity after the initial order.
Follow-Up
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 ANC (DIFF if to be done locally), BUN,
Creatinine, Total bilirubin, AST, and ALT.
Lab Only - Day 15, Cycle 3 – Planned for 1/31/2017
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:40:59 PM Page 5 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
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 4 – 2/14/2017 through 3/13/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:40:59 PM Page 6 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Calculated Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ruxolitinib will be ordered through the medication activity after the initial order.
Follow-Up
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 ANC (DIFF if to be done locally), BUN,
Creatinine, Total bilirubin, AST, and ALT.
Lab Only - Day 15, Cycle 4 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
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
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,Andrew [2428787]
11/22/2016 12:40:59 PM Page 7 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/14/2017 through 4/10/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Calculated Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ruxolitinib will be ordered through the medication activity after the initial order.
Follow-Up
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,Andrew [2428787]
11/22/2016 12:40:59 PM Page 8 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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 ANC (DIFF if to be done locally), BUN,
Creatinine, Total bilirubin, AST, and ALT.
Lab Only - Day 15, Cycle 5 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
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 6 – 4/11/2017 through 5/8/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:40:59 PM Page 9 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Calculated Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ruxolitinib will be ordered through the medication activity after the initial order.
Follow-Up
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 ANC (DIFF if to be done locally), BUN,
Creatinine, Total bilirubin, AST, and ALT.
Lab Only - Day 15, Cycle 6 – Planned for 4/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelofibrosis (Intermediate or high-risk); THERAPY: ruxolitinib (dose per protocol) by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression or lack of effect after 6 months.
Dose Per Protocol
The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20 mg by mouth twice daily
continuously. The recommended starting dose for patients with platelet count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice
daily continuously. Today's starting dose is *** mg based on current platelet count of *** K/µL.
Note to All Staff (1)
When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example, ketoconazole, itraconazole, clarithromycin,
atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) consider a reduction of ruxolitinib
starting dose to 10 mg by mouth twice daily for patients with a platelet count greater than or equal to 100K/µL.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:40:59 PM Page 10 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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.
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/22/2016 12:40:59 PM Page 11 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org