/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/,

/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/name-101580-en.cckm

201611326

page

100

UWHC,UWMF,

Tools,

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

CSC HEM Dexamethasone(28D:1,8,15,22) Ixazomib(28D:1,8,15) Lenalidomide(28D:1-21) VER 10-3-16 (HL 5843)

CSC HEM Dexamethasone(28D:1,8,15,22) Ixazomib(28D:1,8,15) Lenalidomide(28D:1-21) VER 10-3-16 (HL 5843) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM DEXAMETHASONE(28D:1,8,15,22)/IXAZOMIB(28D:1,8,15)/LENALIDOMIDE(28D:1-21) 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: Multiple Myeloma (Advanced); THERAPY: dexamethasone 40 mg by mouth Days 1, 8, 15 and 22, ixazomib 4 mg by
mouth Days 1, 8 and 15, lenalidomide 25 mg by mouth once daily Days 1 through 21; CYCLE LENGTH: 28 days; COURSE: until
disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff (1)
For elderly or frail patients, consider lower starting doses of lenalidomide (15 mg) and ixazomib (3 mg).
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Take Home Medications (delete all that do not apply)
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
aspirin 325 MG EC tab
Take 1 tab by mouth one time daily., 325 mg, Disp-30 tab, R-11, 1 X DAILY starting S
enoxaparin (LOVENOX) 40 MG/0.4ML injection
Inject 40 mg under skin one time daily., 40 mg, Disp-30 Syringe, R-11, 1 X DAILY starting S
warfarin (COUMADIN) 5 MG tab
Take 1 tab by mouth one time daily at bedtime., 5 mg, Disp-30 tab, R-11, 1 X DAILY (HS) starting S
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Moreau P, et al. N Engl J Med 2016;374(17):1621-34.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 1 of 10
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: Multiple Myeloma (Advanced); THERAPY: dexamethasone 40 mg by mouth Days 1, 8, 15 and 22, ixazomib 4 mg by
mouth Days 1, 8 and 15, lenalidomide 25 mg by mouth once daily Days 1 through 21; CYCLE LENGTH: 28 days; COURSE: until
disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff (1)
For elderly or frail patients, consider lower starting doses of lenalidomide (15 mg) and ixazomib (3 mg).
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, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 60 mL/min or AST greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 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)).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone, ixazomib and lenalidomide
(dispensed Day 1 of each cycle).
Take Home Medications
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.
ixazomib citrate (NINLARO) 4 MG cap
Take 1 cap by mouth on Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, AST, ALT, Total
Bilirubin. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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: Multiple Myeloma (Advanced); THERAPY: dexamethasone 40 mg by mouth Days 1, 8, 15 and 22, ixazomib 4 mg by
mouth Days 1, 8 and 15, lenalidomide 25 mg by mouth once daily Days 1 through 21; CYCLE LENGTH: 28 days; COURSE: until
disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 2 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 60 mL/min or AST greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 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).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone, ixazomib and lenalidomide
(dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Take Home Medications (delete all that do not apply)
ixazomib citrate (NINLARO) 4 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 2.3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Day 1 through 21., 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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 3 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, AST, ALT, Total
Bilirubin. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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: Multiple Myeloma (Advanced); THERAPY: dexamethasone 40 mg by mouth Days 1, 8, 15 and 22, ixazomib 4 mg by
mouth Days 1, 8 and 15, lenalidomide 25 mg by mouth once daily Days 1 through 21; CYCLE LENGTH: 28 days; COURSE: until
disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
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
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 60 mL/min or AST greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 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);
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 4 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone, ixazomib and lenalidomide
(dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Take Home Medications (delete all that do not apply)
ixazomib citrate (NINLARO) 4 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 2.3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Day 1 through 21., 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.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, AST, ALT, Total
Bilirubin. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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: Multiple Myeloma (Advanced); THERAPY: dexamethasone 40 mg by mouth Days 1, 8, 15 and 22, ixazomib 4 mg by
mouth Days 1, 8 and 15, lenalidomide 25 mg by mouth once daily Days 1 through 21; CYCLE LENGTH: 28 days; COURSE: until
disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
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 2:14:09 PM Page 5 of 10
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+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 60 mL/min or AST greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 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).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone, ixazomib and lenalidomide
(dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Take Home Medications (delete all that do not apply)
ixazomib citrate (NINLARO) 4 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 2.3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Day 1 through 21., 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.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 6 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, AST, ALT, Total
Bilirubin. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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: Multiple Myeloma (Advanced); THERAPY: dexamethasone 40 mg by mouth Days 1, 8, 15 and 22, ixazomib 4 mg by
mouth Days 1, 8 and 15, lenalidomide 25 mg by mouth once daily Days 1 through 21; CYCLE LENGTH: 28 days; COURSE: until
disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
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
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 60 mL/min or AST greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 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).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone, ixazomib and lenalidomide
(dispensed Day 1 of each cycle).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 7 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Take Home Medications (delete all that do not apply)
ixazomib citrate (NINLARO) 4 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 2.3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Day 1 through 21., 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.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, AST, ALT, Total
Bilirubin. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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: Multiple Myeloma (Advanced); THERAPY: dexamethasone 40 mg by mouth Days 1, 8, 15 and 22, ixazomib 4 mg by
mouth Days 1, 8 and 15, lenalidomide 25 mg by mouth once daily Days 1 through 21; CYCLE LENGTH: 28 days; COURSE: until
disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
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
CREATININE
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 8 of 10
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
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 60 mL/min or AST greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 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).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone, ixazomib and lenalidomide
(dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Take Home Medications (delete all that do not apply)
ixazomib citrate (NINLARO) 4 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
ixazomib citrate (NINLARO) 2.3 MG cap
Take 1 cap by mouth Day 1, 8 and 15. Take at least 1 hour before or 2 hours after food., Disp-3 cap, R-0, starting S
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Day 1 through 21., 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.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily. Take on Day 1 through 21., R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, AST, ALT, Total
Bilirubin. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 9 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ZZtestonc,Andrew [2428787]
11/21/2016 2:14:09 PM Page 10 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org