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CSC HEM CLL Chlorambucil(28D:1,15) Obinutuzumab VER 9-15-17 (HL 5522)

CSC HEM CLL Chlorambucil(28D:1,15) Obinutuzumab VER 9-15-17 (HL 5522) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM CLL CHLORAMBUCIL(28D:1,15)/OBINUTUZUMAB VER: 9-15-17 – Properties
Pre-Cycle – 9/12/2017 through 9/18/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 1 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth once daily for 7 days of Cycle 1. Start 1 day prior to 1st obinutuzumab dose., Disp-7 tab, R-0, starting S, Local
Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
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
Cycle 1 – 9/19/2017 through 10/16/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 9/19/2017
Treatment Plan Information
Reference Information (1)
CHRONIC LYMPHOCYTIC LEUKEMIA: Goede V, et al. N Engl J Med 2014;370(12):1101-10.
Reference Information (2)
CHRONIC LYMPHOCYTIC LEUKEMIA: Lee H, et al. Clin Cancer Res 2014;20(16):3902-07.
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 2 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration (delete all that do not apply)
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 100 mg in sodium chloride 0.9 % 100 mL infusion
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at 25 mg/hr (27.3 mL/hr) over 4 hours. DO NOT increase infusion rate. Hypersensitivity reactions to obinutuzumab can
occur. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Take Home Medications
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 3 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

chlorambucil (LEUKERAN) 2 MG tab
Take *** tabs by mouth once daily on Days 1 and 15. Take on empty stomach., R-0, starting S, Local Printer
Dosing based on 0.5 mg/kg/day.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, LDH, Phosphate; CHEMOTHERAPY ROOM APPOINTMENT:
obinutuzumab for 360 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid; CHEMOTHERAPY ROOM APPOINTMENT:
obinutuzumab for 270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid; CHEMOTHERAPY ROOM APPOINTMENT:
obinutuzumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC: for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, LDH; CHEMOTHERAPY ROOM APPOINTMENT: obinutuzumab for 270 minutes.
Day 2, Cycle 1 – Planned for 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+1 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+1 Approximate, Expires-S+365, Routine
BUN
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+1 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
LD, TOTAL
Expected-S+1 Approximate, Expires-S+365, Routine
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 4 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration (delete all that do not apply)
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 900 mg in sodium chloride 0.9 % 250 mL infusion
900 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at 50 mg/hr (17.3 mL/hr). The rate of infusion can be escalated in increments of 50 mg/hr (17.3 mL/hr) every 30 minutes
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 5 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

to a maximum rate of 400 mg/hr (138.3 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second dose
patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+6 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+6 Approximate, Expires-S+365, Routine
BUN
Expected-S+6 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+6 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+6 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+6 Approximate, Expires-S+365, Routine
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 6 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 7 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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
URIC ACID
Expected-S+7 Approximate, Expires-S+365, Routine
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 8 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 10/17/2017 through 11/13/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 9 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 10 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take *** tabs by mouth once daily on Days 1 and 15. Take on empty stomach., R-0, starting S, Local Printer
Dosing based on 0.5 mg/kg/day.
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 DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, LDH.
CHEMOTHERAPY ROOM APPOINTMENT: obinutuzumab for 270 minutes.
Lab Only - Day 15, Cycle 2 – Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 11 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 11/14/2017 through 12/11/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 12 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 13 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take *** tabs by mouth once daily on Days 1 and 15. Take on empty stomach., R-0, starting S, Local Printer
Dosing based on 0.5 mg/kg/day.
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 DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, LDH.
CHEMOTHERAPY ROOM APPOINTMENT: obinutuzumab for 270 minutes.
Lab Only - Day 15, Cycle 3 – Planned for 11/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
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 – 12/12/2017 through 1/8/2018 (28 days), Planned
Day 1, Cycle 4 – Planned for 12/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 14 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 15 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take *** tabs by mouth once daily on Days 1 and 15. Take on empty stomach., R-0, starting S, Local Printer
Dosing based on 0.5 mg/kg/day.
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 DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, LDH.
CHEMOTHERAPY ROOM APPOINTMENT: obinutuzumab for 270 minutes.
Lab Only - Day 15, Cycle 4 – Planned for 12/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 16 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 1/9/2018 through 2/5/2018 (28 days), Planned
Day 1, Cycle 5 – Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 17 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 18 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take *** tabs by mouth once daily on Days 1 and 15. Take on empty stomach., R-0, starting S, Local Printer
Dosing based on 0.5 mg/kg/day.
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 DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, LDH.
CHEMOTHERAPY ROOM APPOINTMENT: obinutuzumab for 270 minutes.
Lab Only - Day 15, Cycle 5 – Planned for 1/23/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
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 – 2/6/2018 through 3/5/2018 (28 days), Planned
Day 1, Cycle 6 – Planned for 2/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
Note to All Staff (2)
Consider withholding antihypertensive medications for 12 hours prior to and throughout each obinutuzumab infusion and for the first
hour after administration.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 19 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to obinutuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vitals Signs every 15 minutes for the first hour during obinutuzumab infusion, then every hour until the end of infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Administer at least 30 minutes prior to obinutuzumab infusion.
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 20 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer at least 60 minutes prior to obinutuzumab infusion. For patients with previous severe infusion reaction or lymphocyte
count greater than 25K/uL.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer at least 30 minutes prior to obinutuzumab infusion. For patients with previous infusion reaction.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
obinutuzumab (GAZYVA) 1,000 mg in sodium chloride 0.9 % 250 mL infusion
1,000 mg, Intravenous, ONCE, 1 dose Starting when released
Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30
minutes to a maximum rate of 400 mg/hr (126 mL/hr). Hypersensitivity reactions to obinutuzumab can occur. For first and second
dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: chlorambucil (dispensed Day 1 of each cycle).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take *** tabs by mouth once daily on Days 1 and 15. Take on empty stomach., R-0, starting S, Local Printer
Dosing based on 0.5 mg/kg/day.
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.
Lab Only - Day 15, Cycle 6 – Planned for 2/20/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia; THERAPY: obinutuzumab 100 mg IV Day 1, obinutuzumab 900 mg IV Day 2,
obinutuzumab 1,000 mg IV on Day 8 and 15, chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: 1 Cycle followed by THERAPY: obinutuzumab 1,000 mg IV Day 1, chlorambucil 0.5 mg/kg by mouth once daily on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 5 Cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in fulminant hepatitis, hepatic
failure and death. Screen all patients for HBV infection before treatment initiation.
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,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 21 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
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Zztestonc,Ondra O [2507491]
9/19/2017 5:01:11 PM Page 22 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org