/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-96877-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Lenalidomide(28D:1-21) Rituximab(28D:1,8,15,22 Cycle 1 Only) VER 10-3-16 (HL 5037)

CSC HEM Lenalidomide(28D:1-21) Rituximab(28D:1,8,15,22 Cycle 1 Only) VER 10-3-16 (HL 5037) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM LENALIDOMIDE (28D:1-21) RITUXIMAB (28D:1,8,15,22 CYCLE 1 ONLY) VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
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
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
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
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 1 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Expected-S Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+122, Routine
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
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)
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
aspirin 325 MG EC tab
Take 1 tab by mouth one time daily., 325 mg, Disp-30 tab, R-11, 1 X DAILY starting S
enoxaparin (LOVENOX) 40 MG/0.4ML injection
Inject 40 mg under skin one time daily., 40 mg, Disp-30 Syringe, R-11, 1 X DAILY starting S
warfarin (COUMADIN) 5 MG tab
Take 1 tab by mouth one time daily at bedtime., 5 mg, Disp-30 tab, R-11, 1 X DAILY (HS) starting S
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
MANTLE CELL LYMPHOMA: Wong M, et al. Lancet Oncol 2012;13:726-23.
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 2 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+122, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 3 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
lenalidomide (REVLIMID) 10 MG cap
Take 2 caps by mouth one time daily. Take on Day 1 through 21., 20 mg, Disp-42 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential). CHEMOTHERAPY ROOM APPOINTMENT:
rituximab for 180 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential). CHEMOTHERAPY ROOM APPOINTMENT:
rituximab for 180 minutes.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential). CHEMOTHERAPY ROOM APPOINTMENT:
rituximab for 180 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urine Pregnancy Test (for women of
child-bearing potential).
Day 8, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 4 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 5 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
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
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
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 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 6 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 7 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 8 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
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
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 9 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
MANTLE CELL LYMPHOMA: Wong M, et al. Lancet Oncol 2012;13:726-23.
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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 WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 10 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALBUMIN
Expected-S+7 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
Dose Calculation Instructions
Provider to document reason for lenalidomide dose modification in Treatment Plan Modification order per treatment parameters or if
ANC less than 1000/µL for 7 days or if ANC falls below 1000/µL with temperature 38.5 degrees or if ANC falls below 500/µL.
Resume lenalidomide at 5 mg less than previous dose when ANC greater than or equal to 1000/µL and when Platelets are greater
than or equal to 50K/µL.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
LAB ONLY: CBC with DIFF, Urine Pregnancy Test if periods are irregular (for women of child-bearing potential).
DAY 29 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 11 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urine Pregnancy Test (for women of
child-bearing potential).
Lab Only - Day 15, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
Nursing Procedure, Assessment and Monitoring
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Reference Information (1)
MANTLE CELL LYMPHOMA: Wong M, et al. Lancet Oncol 2012;13:726-23.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 12 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
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
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 13 of 21
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
Dose Calculation Instructions
Provider to document reason for lenalidomide dose modification in Treatment Plan Modification order per treatment parameters or if
ANC less than 1000/µL for 7 days or if ANC falls below 1000/µL with temperature 38.5 degrees or if ANC falls below 500/µL.
Resume lenalidomide at 5 mg less than previous dose when ANC greater than or equal to 1000/µL and when Platelets are greater
than or equal to 50K/µL.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
LAB ONLY: CBC with DIFF, Urine Pregnancy Test if periods are irregular (for women of child-bearing potential).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urine Pregnancy Test (for women of
child-bearing potential).
Lab Only - Day 15, Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 14 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Nursing Procedure, Assessment and Monitoring
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Reference Information (1)
MANTLE CELL LYMPHOMA: Wong M, et al. Lancet Oncol 2012;13:726-23.
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 15 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
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
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 16 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Dose Calculation Instructions
Provider to document reason for lenalidomide dose modification in Treatment Plan Modification order per treatment parameters or if
ANC less than 1000/µL for 7 days or if ANC falls below 1000/µL with temperature 38.5 degrees or if ANC falls below 500/µL.
Resume lenalidomide at 5 mg less than previous dose when ANC greater than or equal to 1000/µL and when Platelets are greater
than or equal to 50K/µL.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
LAB ONLY: CBC with DIFF, Urine Pregnancy Test if periods are irregular (for women of child-bearing potential).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urine Pregnancy Test (for women of
child-bearing potential).
Lab Only - Day 15, Cycle 4 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
Nursing Procedure, Assessment and Monitoring
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 17 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Reference Information (1)
MANTLE CELL LYMPHOMA: Wong M, et al. Lancet Oncol 2012;13:726-23.
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
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
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 18 of 21
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
PROTEIN, TOTAL
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
Dose Calculation Instructions
Provider to document reason for lenalidomide dose modification in Treatment Plan Modification order per treatment parameters or if
ANC less than 1000/µL for 7 days or if ANC falls below 1000/µL with temperature 38.5 degrees or if ANC falls below 500/µL.
Resume lenalidomide at 5 mg less than previous dose when ANC greater than or equal to 1000/µL and when Platelets are greater
than or equal to 50K/µL.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urine Pregnancy Test (for women of
child-bearing potential).
Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 19 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Reference Information (1)
MANTLE CELL LYMPHOMA: Wong M, et al. Lancet Oncol 2012;13:726-23.
Treatment Plan Summary
DISEASE: Mantle Cell Lymphoma (Relapsed/ Progressive Disease); THERAPY: rituximab 375 mg/m2 IV Days 1, 8, 15 and 22,
lenalidomide 20 mg by mouth once daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 1 Cycle followed by THERAPY:
lenalidomide 20 mg by mouth once daily Day 1 through 21: CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Consider holding treatment for ANC less than 1000/uL for greater than or equal to 7 days or ANC less than 1000/µL with associated
fever greater than or equal to 38.5 C or ANC less than 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose
once ANC recovers to greater than or equal to 1000/µL and Platelets greater than or equal to 50K/µL.
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
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
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 20 of 21
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
Dose Calculation Instructions
Provider to document reason for lenalidomide dose modification in Treatment Plan Modification order per treatment parameters or if
ANC less than 1000/µL for 7 days or if ANC falls below 1000/µL with temperature 38.5 degrees or if ANC falls below 500/µL.
Resume lenalidomide at 5 mg less than previous dose when ANC greater than or equal to 1000/µL and when Platelets are greater
than or equal to 50K/µL.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urine Pregnancy Test (for women of
child-bearing potential).
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ZZtestonc,Andrew [2428787]
11/21/2016 3:21:19 PM Page 21 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org