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/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96899-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) With Rituximab VER 10-3-16 (HL 5409)

CSC HEM Idelalisib(28D:1-28) With Rituximab VER 10-3-16 (HL 5409) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM IDELALISIB(28D:1-28) WITH RITUXIMAB 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 Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 1 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
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
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
CMV AB, IGG (IMMUNE STATUS)
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B DNA, ULTRA QUANT, PCR
Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
CMV QUANTITATIVE BY PCR
Expected-S Approximate, Expires-S+365, Routine
Draw if CMV Ab is positive.
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 CHRONIC LYMPHOCYTIC LEUKEMIA/ SMALL LYMPHOCYTIC LYMPHOMA: Furman R, et al. N Engl
J Med 2014;370(11):997-1007.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 2 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY:
rituximab 375 mg/m2 IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15,
idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH:
28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
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 3:09:18 PM Page 3 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 4 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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, Calcium, Uric Acid, Magnesium, Phosphate, LDH.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST; CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
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;
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
Lab Only - Day 3, Cycle 1 – Planned for 11/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 5 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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 Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 6 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
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
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+7 Approximate, Expires-S+365, Routine
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.
Day 15, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 7 of 31
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 (4)
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
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
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.
Hydration
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 8 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 895 mg in sodium chloride 0.9 % 500 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on Day 1 of each Cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 9 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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
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 Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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 3:09:18 PM Page 10 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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+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
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+14 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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 11 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 895 mg in sodium chloride 0.9 % 500 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): 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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 12 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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; CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST;
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
Day 15, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 13 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 14 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 895 mg in sodium chloride 0.9 % 500 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): idelalisib (dispensed on 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 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 Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 15 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
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
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+14 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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 16 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
rituximab (RITUXAN) 895 mg in sodium chloride 0.9 % 500 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): 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;
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
Lab Only - Day 15 , Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 17 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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 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 Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 18 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+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
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+14 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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
Patient Instructions(1)
Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per day.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 19 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
rituximab (RITUXAN) 895 mg in sodium chloride 0.9 % 500 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): 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;
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
Lab Only - Day 15 , Cycle 4 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 20 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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 Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 21 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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, QUALITATIVE
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
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.
Monitoring Parameters (4)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 22 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
rituximab (RITUXAN) 895 mg in sodium chloride 0.9 % 500 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): 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;
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
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 Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 23 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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, QUALITATIVE
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
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 24 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than
6 months since last dose. For first and second dose patient should be treated in a location to optimize emergency
care. See Emergency Meds.
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Blood Pressure, Heart Rate, Respiratory Rate, Temperature, and Pulse Oximetry. Monitor Vital Signs every 15 minutes for
the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient experiences fever accompanied by chills
or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD. Once the patient returns to baseline,
infusion may be restarted at half the rate during which the reaction occurred.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
rituximab (RITUXAN) 895 mg in sodium chloride 0.9 % 500 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): 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 3:09:18 PM Page 25 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 7 – 5/8/2017 through 6/4/2017 (28 days), Planned
Day 1, Cycle 7 – Planned for 5/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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, QUALITATIVE
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 26 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, 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 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
Cycle 8 – 6/5/2017 through 7/2/2017 (28 days), Planned
Day 1, Cycle 8 – Planned for 6/5/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 27 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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, QUALITATIVE
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 28 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
Cycle 9 – 7/3/2017 through 7/30/2017 (28 days), Planned
Day 1, Cycle 9 – Planned for 7/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed/Refractory Chronic Lymphocytic Leukemia/ Small Lymphocytic Lymphoma; THERAPY: rituximab 375 mg/m2
IV Day 1, rituximab 500 mg/m2 Day 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1 and 15, idelalisib 150 mg by mouth twice daily continuously; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY: rituximab 500 mg/m2 IV Day 1, idelalisib 150 mg by mouth twice daily
continuously; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by 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 3:09:18 PM Page 29 of 31
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)
Please see linked package insert for idelalisib dose modification instructions as clinically appropriate
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Note to all Staff (4)
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, QUALITATIVE
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:09:18 PM Page 30 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 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 3:09:18 PM Page 31 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org