/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-111724-en.cckm

201709268

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100

UWHC,UWMF,

Tools,

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

CSC HEM Daratumumab(28D) Dexamethasone(28D:1,2,8,9,15,16,22,23) Lenalidomide(28D:1-21) VER 9-21-17 (HL 6022)

CSC HEM Daratumumab(28D) Dexamethasone(28D:1,2,8,9,15,16,22,23) Lenalidomide(28D:1-21) VER 9-21-17 (HL 6022) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM DARATUMUMAB(28D)/DEXAMETHASONE(28D:1,2,8,9,15,16,22,23)/LENALIDOMIDE(28D:1-21) VER: 9-21-
17 – Properties
Pre-Cycle – 9/14/2017 through 9/20/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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
TYPE AND SCREEN
Expected-S Approximate, Expires-S+365
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
RBC PHENOTYPING AT ARC
Expected-S Approximate, Expires-S+365, Normal, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
diphenhydramine (BENADRYL) 25 MG cap
Take 1 to 2 capsules by mouth as needed for infusion reaction (may occur up to 4 hours after infusion ends). Available over-the-
counter., Disp-30 cap, R-1, starting S, Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
Continue for 3 months following treatment.
ondansetron (ZOFRAN) 8 MG tab
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 1 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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
montelukast (SINGULAIR) 10 MG tab
Take 1 tab by mouth one time daily at bedtime. Start 5 days prior to daratumumab infusion., 10 mg, Disp-5 tab, R-0, 1 X DAILY (HS)
starting S, Local Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Take Home Medications (delete all that do not apply)
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
Cycle 1 – 9/21/2017 through 10/18/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 9/21/2017
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: Dimopoulos MA, et al. N Engl J Med 2016;375(14):1319-1331.
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise, script will go to
nursing or tech pool. Invalid items: Provider ...Details
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise, script will go to
nursing or tech pool. Invalid items: Provider ...Details
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise, script will go to
nursing or tech pool. Invalid items: Provider ...Details
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise, script will go to
nursing or tech pool. Invalid items: Provider ...Details
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 2 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or
Hemoglobin less than 7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline
Phosphatase greater than 3.5 X ULN or Total Bilirubin greater than 2.5 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)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 3 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 60 minutes prior to start of infusion.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 1,000 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 2, 8, 9, 15, 16, 22 and 23 prior to daratumumab treatment and the day after, Disp-35 tab, R-0, starting S, Local
Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 390 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY
ROOM APPOINTMENT: daratumumab for 270 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Day 8, Cycle 1 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff (1)
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 4 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
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)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 5 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 6 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29
(Day 1 of next cycle)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 7 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 1 – Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
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)).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 8 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 9 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed
Day 1 of each cycle) 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 2 – 10/19/2017 through 11/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 10 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Hemoglobin less than
7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline Phosphatase greater than 3.5 X ULN or Total
Bilirubin greater than 2.5 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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 11 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Days 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) 15 MG cap
Take by mouth one time daily. Take on Days 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 Days 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 Days 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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 8, 9, 15, 16, 22 and 23 prior to daratumumab treatment and the day after, Disp-40 tab, R-0, starting S,
Local Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin and Urine Pregnancy Test (women of childbearing potential);
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 12 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Day 8, Cycle 2 – Planned for 10/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 13 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 14 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 15 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 16 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Follow-Up
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 17 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 11/16/2017 through 12/13/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
Treatment Parameters
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 18 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Hemoglobin less than
7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline Phosphatase greater than 3.5 X ULN or Total
Bilirubin greater than 2.5 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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 19 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Days 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) 15 MG cap
Take by mouth one time daily. Take on Days 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 Days 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 Days 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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 8, 9, 15, 16, 22, 23. On daratumumab days, take prior to daratumumab, Disp-40 tab, R-0, starting S, Local
Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin and Urine Pregnancy Test (women of childbearing potential);
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 3 – Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 20 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 21 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 – 12/14/2017 through 1/10/2018 (28 days), Planned
Day 1, Cycle 4 – Planned for 12/14/2017
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 22 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Hemoglobin less than
7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline Phosphatase greater than 3.5 X ULN or Total
Bilirubin greater than 2.5 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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 23 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 24 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Days 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) 15 MG cap
Take by mouth one time daily. Take on Days 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 Days 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 Days 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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 8, 9, 15, 16, 22, 23. On daratumumab days, take prior to daratumumab, Disp-40 tab, R-0, starting S, Local
Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin and Urine Pregnancy Test (women of childbearing potential);
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 4 – Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 25 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 26 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 – 1/11/2018 through 2/7/2018 (28 days), Planned
Day 1, Cycle 5 – Planned for 1/11/2018
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 27 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Hemoglobin less than
7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline Phosphatase greater than 3.5 X ULN or Total
Bilirubin greater than 2.5 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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 28 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 29 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Days 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) 15 MG cap
Take by mouth one time daily. Take on Days 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 Days 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 Days 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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 8, 9, 15, 16, 22, 23. On daratumumab days, take prior to daratumumab, Disp-40 tab, R-0, starting S, Local
Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin and Urine Pregnancy Test (women of childbearing potential);
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 5 – Planned for 1/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 30 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 31 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 6 – 2/8/2018 through 3/7/2018 (28 days), Planned
Day 1, Cycle 6 – Planned for 2/8/2018
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 32 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Hemoglobin less than
7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline Phosphatase greater than 3.5 X ULN or Total
Bilirubin greater than 2.5 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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 33 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 34 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Days 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) 15 MG cap
Take by mouth one time daily. Take on Days 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 Days 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 Days 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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 8, 9, 15, 16, 22, 23. On daratumumab days, take prior to daratumumab, Disp-40 tab, R-0, starting S, Local
Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential); CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin and Urine Pregnancy Test (women of childbearing potential);
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 6 – Planned for 2/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 35 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 36 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) 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 7 – 3/8/2018 through 4/4/2018 (28 days), Planned
Day 1, Cycle 7 – Planned for 3/8/2018
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 37 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Hemoglobin less than
7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline Phosphatase greater than 3.5 X ULN or Total
Bilirubin greater than 2.5 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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 38 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
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.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 39 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Days 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) 15 MG cap
Take by mouth one time daily. Take on Days 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 Days 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 Days 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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 8, 9, 15, 16, 22, 23. On daratumumab days, take prior to daratumumab, Disp-40 tab, R-0, starting S, Local
Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin and Urine Pregnancy Test (women of childbearing potential);
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Cycle 8 – 4/5/2018 through 5/2/2018 (28 days), Planned
Day 1, Cycle 8 – Planned for 4/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, dexamethasone 20 mg by
mouth Day 1 (IV on Cycle 1 Day 1), 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE
LENGTH: 28 days; COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, dexamethasone 20 mg by
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 40 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

mouth Day 1, 2, 8, 9, 15, 16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days;
COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1, dexamethasone 20 mg by mouth Day 1, 2, 8, 9, 15,
16, 22 and 23, lenalidomide 25 mg by mouth daily Day 1 through Day 21; CYCLE LENGTH: 28 days; COURSE: 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+28 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline Phosphatase and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Hemoglobin less than
7.5 g/dL or Creatinine greater than 2 X ULN or ALT greater than 3.5 X ULN or Alkaline Phosphatase greater than 3.5 X ULN or Total
Bilirubin greater than 2.5 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).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their chemotherapy
appointment.
Flush Venous Access Device per Guidelines
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 41 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@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.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 42 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to start of infusion. For use in patients who did not take dexamethasone at home.
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
16 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every hour to a
maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or greater
infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by 50mL/hr every hour
to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion reactions
during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a maximum rate of
200mL/hr.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily. Take on Days 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) 15 MG cap
Take by mouth one time daily. Take on Days 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 Days 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 Days 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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 8, 9, 15, 16, 22, 23. On daratumumab days, take prior to daratumumab, Disp-40 tab, R-0, starting S, Local
Printer
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to add order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, Glucose,
Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin and Urine Pregnancy Test (women of childbearing potential);
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 2:58:54 PM Page 43 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org