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CSC HEM Elotuzumab Dexamethasone(28D:1,8,15,22) Lenalidomide(28D:1-21) VER 3-8-17 (HL 5850)

CSC HEM Elotuzumab Dexamethasone(28D:1,8,15,22) Lenalidomide(28D:1-21) VER 3-8-17 (HL 5850) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM ELOTUZUMAB/DEXAMETHASONE(28D:1,8,15,22)/LENALIDOMIDE(28D:1-21) VER: 3-8-17 – Properties
Pre-Cycle – 3/2/2017 through 3/8/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 3/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S
Take Home Medications (delete all that do not apply)
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
aspirin EC 325 MG delayed release tab
Take 1 tab by mouth one time daily., 325 mg, Disp-30 tab, R-11, 1 X DAILY starting S
enoxaparin (LOVENOX) 40 MG/0.4ML injection
Inject 40 mg under skin one time daily., 40 mg, Disp-30 Syringe, R-11, 1 X DAILY starting S
warfarin (COUMADIN) 5 MG tab
Take 1 tab by mouth one time daily at bedtime., 5 mg, Disp-30 tab, R-11, 1 X DAILY (HS) starting S
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 7 tabs by mouth once 3 to 24hr prior to etoluzumab infusion on Day 1, 8, 15, 22 and Day 1 of Cycle 2., Disp-35 tab, R-0,
starting S
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 1 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Cycle 1 – 3/9/2017 through 4/5/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 3/9/2017
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: Lonial S, et al. New Eng J Med 2015;373(7):621-31.
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
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, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 2 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@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.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
lenalidomide (REVLIMID) 25 MG cap
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 3 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), AST, ALT,
Total Bilirubin, Alkaline Phosphatase; NOTE: Urine Pregnancy Test to be ordered by MD when required. CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
Day 8, Cycle 1 – Planned for 3/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 4 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 5 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 3/23/2017
Day 22, Cycle 1 – Planned for 3/30/2017
Cycle 2 – 4/6/2017 through 5/3/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 4/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 6 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 7 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 7 tabs by mouth once 3 to 24hr prior to etoluzumab infusion on Day 8, 15, 22 and Day 1 of next cycle., Disp-28 tab, R-0,
starting S
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 8 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), AST, ALT,
Total Bilirubin, Alkaline Phosphatase; NOTE: Urine Pregnancy Test to be ordered by MD when required. CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
Day 8, Cycle 2 – Planned for 4/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Verify Medication(s) Taken at Home (1)
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 9 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 10 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr)
for the next 30 minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr)
until infusion complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion
complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion
and contact MD. Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a
rate of 0.5 mL/min (30 mL/hr) every 30 minutes as tolerated to the rate at which the reaction occurred. Resume
escalation regimen if there is no recurrence of the infusion reaction. If the infusion reaction recurs, stop the infusion,
notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 4/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 11 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 12 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 4/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 13 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 14 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 5/4/2017 through 5/31/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 5/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 15 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 16 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

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
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 7 tabs by mouth once 3 to 24hr before etoluzumab infusion on Day 15 and Day 1 of next Cycle. Take 10 tabs by mouth on
Day 8 & 22, Disp-34 tab, R-0, starting S
lenalidomide (REVLIMID) 25 MG cap
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 17 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), AST, ALT,
Total Bilirubin, Alkaline Phosphatase; NOTE: Urine Pregnancy Test to be ordered by MD when required. CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
Day 15, Cycle 3 – Planned for 5/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 18 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 19 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 6/1/2017 through 6/28/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 6/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
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 WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 20 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 21 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 7 tabs by mouth once 3 to 24hr before etoluzumab infusion on Day 15 and Day 1 of next Cycle. Take 10 tabs by mouth on
Day 8 & 22, Disp-34 tab, R-0, starting S
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), AST, ALT,
Total Bilirubin, Alkaline Phosphatase; NOTE: Urine Pregnancy Test to be ordered by MD when required. CHEMOTHERAPY ROOM
APPOINTMENT: elotuzumab for 150 minutes.
Day 15, Cycle 4 – Planned for 6/15/2017
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 22 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: dexamethasone 28 mg by mouth Day 1, 8, 15 and 22 plus dexamethasone 8
mg IV Day 1, 8, 15, and 22, elotuzumab 10 mg/kg IV Day 1, 8, 15, and 22, lenalidomide 25 mg by mouth daily Day 1 through Day
21; CYCLE LENGTH: 28 days; COURSE: Cycles 1 and 2, followed by:
THERAPY: dexamethasone 28 mg by mouth Day 1 and 15 plus dexamethasone 8 mg IV Day 1 and 15, elotuzumab 10 mg/kg IV
Day 1 and 15, lenalidomide 25 mg by mouth daily Day 1 through Day 21, dexamethasone 40 mg by mouth Day 8 and 22; CYCLE
LENGTH: 28 days; COURSE: starting Cycle 3 and continuing until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or AST
greater than 3 x ULN or ALT greater than 3 x ULN or Total Bilirubin greater than 2 x ULN or Alkaline Phosphatase greater than 2 x
ULN
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reactions to elotuzumab can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Measure vital signs prior to the start of elotuzumab infusion, 30 minutes after the start of the infusion, and at end of infusion. In
patients who experience an infusion reaction, monitor vital signs every 30 minutes for 2 hours after the end of the infusion.
Flush Venous Access Device per Guidelines
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 23 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 45 to 90 minutes prior to elotuzumab infusion.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 45 to 90 minutes prior to elotuzumab infusion.
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
elotuzumab (EMPLICITI) 10 mg/kg in sodium chloride 0.9 % 250 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer with 0.22 micron filter.
Cycle 1, Dose 1: Initiate infusion at 0.5 mL/min (30 mL/hr) for 30 minutes, then increase rate to 1 mL/min (60 mL/hr) for the next 30
minutes, then to a maximum rate of 2 mL/min (120 mL/hr) until infusion complete.
Cycle 1, Dose 2: Initiate infusion at 1 mL/min (60 mL/hr) for 30 minutes, then increase rate to 2 mL/min (120 mL/hr) until infusion
complete.
Cycle 1, Dose 3 and 4 and all subsequent cycles: Administer at a rate of 2 mL/min (120 mL/hr) until infusion complete.
Hypersensitivity risk. See Emergency Medications.
If patient experiences rash, flushing, urticaria, dyspnea or temperature greater than or equal 100.4F, stop infusion and contact MD.
Upon resolution of symptoms, restart infusion at 0.5 mL/min (30 mL/hr) and gradually increase at a rate of 0.5 mL/min (30 mL/hr)
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every 30 minutes as tolerated to the rate at which the reaction occurred. Resume escalation regimen if there is no recurrence of the
infusion reaction. If the infusion reaction recurs, stop the infusion, notify MD and do not restart on that day.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed from Pre-Cycle
and Day 1 of each cycle starting on Cycle 2) and lenalidomide (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 6/29/2017 through 7/26/2017 (28 days), Planned
Cycle 6 – 7/27/2017 through 8/23/2017 (28 days), Planned
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ZZtestonc,Diane D [2466374]
3/9/2017 9:38:29 AM Page 25 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org