/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-96898-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 Idelalisib(28D:1-28) VER 10-3-16 (HL 5194)

CSC HEM Idelalisib(28D:1-28) VER 10-3-16 (HL 5194) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM IDELALISIB(28D:1-28) 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: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 1 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S Approximate, Expires-S+365, Routine
CMV AB, IGG (IMMUNE STATUS)
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
CMV QUANTITATIVE BY PCR
Expected-S Approximate, Expires-S+365, Routine
Draw if CMV Ab is positive.
HCG, QUANTITATIVE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
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
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tablet by mouth twice daily on Saturday and Sunday., Disp-16 tab, R-5, starting S
loperamide (IMODIUM) 2 MG tab
Take 2 tab orally with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max dose=8 tab/day,
Disp-1 each, R-0, starting S, No Print
Counsel patient to purchase over the counter and provide instructions for use.
Take Home Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take on Days 1 through 14 of Cycle 1 only., 300 mg, Disp-14 tab, R-0, 1 X DAILY starting S,
Local Printer
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth 2 times daily. Take on Days 1 through 14 of Cycle 1 only., 300 mg, Disp-28 tab, R-0, 2 X DAILY starting S,
Local Printer
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)
RELAPSED/REFRACTORY FOLLICULAR LYMPHOMA/ SMALL LYMPHOCYTIC LYMPHOMA/ CHRONIC LYMPHOCYTIC
LEUKEMIA: Flinn I, et al. Blood 2014; 123(22):3406-13.
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 2 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/uL or Platelets less than 25K/uL or ALT greater than 5 X ULN or AST
greater than 5 X ULN or Total Bilirubin greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for diarrhea and notify provider if patient reports 6 or more bowel movements per day.
Monitoring Parameters (2)
Assess patient for cough, dyspnea, or pulmonary findings on lung exam that would suggest pneumonia or drug-related pneumonitis.
Document baseline Pulse Oximetry and document Pulse Oximetry with each clinical assessment.
Monitoring Parameters (3)
Monitor patients for signs and symptoms of intestinal perforation. Advise patients to report any new or worsening abdominal pain,
chills, fever, nausea, or vomiting.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry.
Patient Instructions(1)
Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per day.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on Day 1 of each Cycle).
Take Home Medications
idelalisib (ZYDELIG) 150 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 150 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 3 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 3 FOLLOW-UP
LABS: Potassium, Phosphate, Calcium, Uric Acid, LDH, Creatinine.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST, Creatinine, Uric Acid, Calcium, Magnesium, Phosphate, LDH.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
Lab Only - Day 3, Cycle 1 – Planned for 11/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
POTASSIUM
Expected-S+2 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+2 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+2 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+2 Approximate, Expires-S+365, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 4 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+2 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+2 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
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
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
URIC ACID
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 3:07:50 PM Page 5 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+7 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15 , Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
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,Andrew [2428787]
11/21/2016 3:07:50 PM Page 6 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Lab Only - Day 22, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 7 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
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
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, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/uL or Platelets less than 25K/uL or ALT greater than 5 X ULN or AST
greater than 5 X ULN or Total Bilirubin greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for diarrhea and notify provider if patient reports 6 or more bowel movements per day.
Monitoring Parameters (2)
Assess patient for cough, dyspnea, or pulmonary findings on lung exam that would suggest pneumonia or drug-related pneumonitis.
Document baseline Pulse Oximetry and document Pulse Oximetry with each clinical assessment.
Monitoring Parameters (3)
Monitor patients for signs and symptoms of intestinal perforation. Advise patients to report any new or worsening abdominal pain,
chills, fever, nausea, or vomiting.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 8 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry.
Patient Instructions(1)
Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per day.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
idelalisib (ZYDELIG) 100 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 100 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
idelalisib (ZYDELIG) 150 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 150 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
Lab Only - Day 15 , Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 9 of 19
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 (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection
prior to idelalisib treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be
discontinued in patients with evidence of CMV infection or viremia.
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 10 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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
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, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/uL or Platelets less than 25K/uL or ALT greater than 5 X ULN or AST
greater than 5 X ULN or Total Bilirubin greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for diarrhea and notify provider if patient reports 6 or more bowel movements per day.
Monitoring Parameters (2)
Assess patient for cough, dyspnea, or pulmonary findings on lung exam that would suggest pneumonia or drug-related pneumonitis.
Document baseline Pulse Oximetry and document Pulse Oximetry with each clinical assessment.
Monitoring Parameters (3)
Monitor patients for signs and symptoms of intestinal perforation. Advise patients to report any new or worsening abdominal pain,
chills, fever, nausea, or vomiting.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry.
Patient Instructions(1)
Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per day.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on Day 1 of each Cycle).
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 11 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
idelalisib (ZYDELIG) 100 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 100 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
idelalisib (ZYDELIG) 150 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 150 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
Lab Only - Day 15 , Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 12 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
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
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 13 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/uL or Platelets less than 25K/uL or ALT greater than 5 X ULN or AST
greater than 5 X ULN or Total Bilirubin greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for diarrhea and notify provider if patient reports 6 or more bowel movements per day.
Monitoring Parameters (2)
Assess patient for cough, dyspnea, or pulmonary findings on lung exam that would suggest pneumonia or drug-related pneumonitis.
Document baseline Pulse Oximetry and document Pulse Oximetry with each clinical assessment.
Monitoring Parameters (3)
Monitor patients for signs and symptoms of intestinal perforation. Advise patients to report any new or worsening abdominal pain,
chills, fever, nausea, or vomiting.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry.
Patient Instructions(1)
Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per day.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
idelalisib (ZYDELIG) 100 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 100 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
idelalisib (ZYDELIG) 150 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 150 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
Lab Only - Day 15 , Cycle 4 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 14 of 19
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)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and
during treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of
severe diarrhea or colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms
and bilateral interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal
pain, chills, fever, nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which
does not signify disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of
idelalisib treatment and may persist for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
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 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 15 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
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
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
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, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/uL or Platelets less than 25K/uL or ALT greater than 5 X ULN or AST
greater than 5 X ULN or Total Bilirubin greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for diarrhea and notify provider if patient reports 6 or more bowel movements per day.
Monitoring Parameters (2)
Assess patient for cough, dyspnea, or pulmonary findings on lung exam that would suggest pneumonia or drug-related pneumonitis.
Document baseline Pulse Oximetry and document Pulse Oximetry with each clinical assessment.
Monitoring Parameters (3)
Monitor patients for signs and symptoms of intestinal perforation. Advise patients to report any new or worsening abdominal pain,
chills, fever, nausea, or vomiting.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry.
Patient Instructions(1)
Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per day.
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 16 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
idelalisib (ZYDELIG) 100 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 100 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
idelalisib (ZYDELIG) 150 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 150 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Follicular Lymphoma/ Small Lymphocytic Lymphoma/ Chronic Lymphocytic Leukemia; THERAPY:
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor hepatic function prior to and during
treatment.
Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development of severe diarrhea or
colitis.
Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary symptoms and bilateral
interstitial infiltrates.
Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal pain, chills, fever,
nausea, or vomiting.
Upon initiation of idelalisib, transient increase in Absolute Lymphocyte Count is expected in most patients, which does not signify
disease progression. This onset of isolated lymphocytosis occurs during the first few weeks of idelalisib treatment and may persist
for several weeks of treatment.
Note to All Staff (2)
See package insert for dose modification instructions as clinically appropriate.
Note to all Staff (3)
Cytomegalovirus (CMV) infection may occur and in some cases result in death. Screen patients for CMV infection prior to idelalisib
treatment and consider repeat CMV titers as clinically appropriate. Idelalisib treatment should be discontinued in patients with
evidence of CMV infection or viremia.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 17 of 19
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
CBC WITH DIFFERENTIAL
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
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, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/uL or Platelets less than 25K/uL or ALT greater than 5 X ULN or AST
greater than 5 X ULN or Total Bilirubin greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for diarrhea and notify provider if patient reports 6 or more bowel movements per day.
Monitoring Parameters (2)
Assess patient for cough, dyspnea, or pulmonary findings on lung exam that would suggest pneumonia or drug-related pneumonitis.
Document baseline Pulse Oximetry and document Pulse Oximetry with each clinical assessment.
Monitoring Parameters (3)
Monitor patients for signs and symptoms of intestinal perforation. Advise patients to report any new or worsening abdominal pain,
chills, fever, nausea, or vomiting.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry.
Patient Instructions(1)
Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per day.
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.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 18 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
idelalisib (ZYDELIG) 100 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 100 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
idelalisib (ZYDELIG) 150 MG tab
Take 1 tab by mouth 2 times daily. Take with or without food. Swallow tablets whole., 150 mg, Disp-60 tab, R-0, 2 X DAILY starting
S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:07:50 PM Page 19 of 19
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org