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201706172

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

CSC HEM Brentuximab(21D:1) VER 6-21-17 (HL 4363)

CSC HEM Brentuximab(21D:1) VER 6-21-17 (HL 4363) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM BRENTUXIMAB(21D:1) VER: 6-21-17 – Properties
Pre-Cycle – 6/14/2017 through 6/20/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE(s): Hodgkin Lymphoma and Anaplastic Large Cell Lymphoma; THERAPY: brentuximab 1.8 mg/kg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: Maximum of 16 cycles. NOTE: Use maximum weight of 100 kg for calculating dose.
Note to All Staff (1)
Regimen is approved for:
1) Hodgkin lymphoma: Approved to be given after failure of autologous stem cell transplant or after failure of at least two prior multi-
agent chemotherapy regimens in patients who are not ASCT candidates.
2) Anaplastic large cell lymphoma: Approved to be given after failure of at least one prior multi-agent chemotherapy regimen.
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
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Allergy/Contraindication: Red Dye Reactions: Agitation
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/21/2017 through 7/11/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/21/2017
Treatment Plan Information
Reference Information (1)
HODGKIN LYMPHOMA/ANAPLASTIC LARGE CELL LYMPHOMA: Younes A, et al. N Engl J Med 2010;363(19):1812-21
Reference Information (2)
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ZZtestonc,Andrew [2428787]
6/21/2017 9:01:12 AM Page 1 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

HODGKIN LYMPHOMA: Younes A, et al. J Clin Oncol 2012;30(18):2183-9.
Reference Information (3)
ANAPLASTIC LARGE CELL LYMPHOMA: Pro B, et al. J Clin Oncol 2012;30(18):2190-6
Treatment Plan Summary
DISEASE(s): Hodgkin Lymphoma and Anaplastic Large Cell Lymphoma; THERAPY: brentuximab 1.8 mg/kg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: Maximum of 16 cycles. NOTE: Use maximum weight of 100 kg for calculating dose.
Note to All Staff (1)
Regimen is approved for:
1) Hodgkin lymphoma: Approved to be given after failure of autologous stem cell transplant or after failure of at least two prior multi-
agent chemotherapy regimens in patients who are not ASCT candidates.
2) Anaplastic large cell lymphoma: Approved to be given after failure of at least one prior multi-agent chemotherapy regimen.
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 1000/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to brentuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
6/21/2017 9:01:12 AM Page 2 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
Allergy/Contraindication: Red Dye Reactions: Agitation
25 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
brentuximab (ADCETRIS) 1.8 mg/kg in sodium chloride 0.9 % 250 mL bag
1.8 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Use a maximum weight of 100 kg for calculating brentuximab dose.
Follow-Up
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally); LABS (prior to every ODD cycle only):
Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: brentuximab for 60 minutes.
Cycle 2 – 7/12/2017 through 8/1/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE(s): Hodgkin Lymphoma and Anaplastic Large Cell Lymphoma; THERAPY: brentuximab 1.8 mg/kg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: Maximum of 16 cycles. NOTE: Use maximum weight of 100 kg for calculating dose.
Note to All Staff (1)
Regimen is approved for:
1) Hodgkin lymphoma: Approved to be given after failure of autologous stem cell transplant or after failure of at least two prior multi-
agent chemotherapy regimens in patients who are not ASCT candidates.
2) Anaplastic large cell lymphoma: Approved to be given after failure of at least one prior multi-agent chemotherapy regimen.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Prior to every ODD cycle only.
AST/SGOT
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ZZtestonc,Andrew [2428787]
6/21/2017 9:01:12 AM Page 3 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Prior to every ODD cycle only.
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Prior to every ODD cycle only.
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Prior to every ODD cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC and ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to brentuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
diphenhydramine (BENADRYL) cap 25 mg
Allergy/Contraindication: Red Dye Reactions: Agitation
25 mg, Oral, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
6/21/2017 9:01:12 AM Page 4 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
brentuximab (ADCETRIS) 1.8 mg/kg in sodium chloride 0.9 % 250 mL bag
1.8 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Use a maximum weight of 100 kg for calculating brentuximab dose.
Follow-Up
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally); LABS (prior to every ODD cycle only):
Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: brentuximab for 60 minutes.
Cycle 3 – 8/2/2017 through 8/22/2017 (21 days), Planned
Cycle 4 – 8/23/2017 through 9/12/2017 (21 days), Planned
Cycle 5 – 9/13/2017 through 10/3/2017 (21 days), Planned
Cycle 6 – 10/4/2017 through 10/24/2017 (21 days), Planned
Cycle 7 – 10/25/2017 through 11/14/2017 (21 days), Planned
Cycle 8 – 11/15/2017 through 12/5/2017 (21 days), Planned
Cycle 9 – 12/6/2017 through 12/26/2017 (21 days), Planned
Cycle 10 – 12/27/2017 through 1/16/2018 (21 days), Planned
Cycle 11 – 1/17/2018 through 2/6/2018 (21 days), Planned
Cycle 12 – 2/7/2018 through 2/27/2018 (21 days), Planned
Cycle 13 – 2/28/2018 through 3/20/2018 (21 days), Planned
Cycle 14 – 3/21/2018 through 4/10/2018 (21 days), Planned
Cycle 15 – 4/11/2018 through 5/1/2018 (21 days), Planned
Cycle 16 – 5/2/2018 through 5/22/2018 (21 days), Planned
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ZZtestonc,Andrew [2428787]
6/21/2017 9:01:12 AM Page 5 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org