/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-115955-en.cckm

201709268

page

100

UWHC,UWMF,

Tools,

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

CSC HEM Bortezomib(21D:1,4,8,11) Daratumumab(21/28D) Dexamethasone (21D:1,2,4,5,8,9,11,12) VER 9-21-17 (HL 6336)

CSC HEM Bortezomib(21D:1,4,8,11) Daratumumab(21/28D) Dexamethasone (21D:1,2,4,5,8,9,11,12) VER 9-21-17 (HL 6336) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM BORTEZOMIB(21D:1,4,8,11)/DARATUMUMAB(21/28D)/DEXAMETHASONE (21D:1,2,4,5,8,9,11,12) 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: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 1 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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
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
Cycle 1 – 9/21/2017 through 10/11/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 9/21/2017
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: Palumbo A, et al. N Engl J Med 2016;375(8):754-66.
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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.
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.
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.
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 3:46:57 PM Page 2 of 56
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, 1 dose Starting when released
Administer 60 minutes prior to start of infusion.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 3 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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).
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 2, 4, 5, 8, 9, 11, 12, 15 and 16 prior to treatment and the day after, Disp-45 tab, R-0, starting S, E-Prescribe
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab and bortezomib for 390 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab and bortezomib for 270 minutes.
Day 4, Cycle 1 – Planned for 9/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
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
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 3:46:57 PM Page 4 of 56
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.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 5 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 6 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 1 – Planned for 10/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 7 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1),
2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1,
8, and 15; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth
Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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 3:46:57 PM Page 8 of 56
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 10/12/2017 through 11/1/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 9 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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
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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 10 of 56
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.
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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Take Home Medications
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 11 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 4, 5, 8, 9, 11, 12, 15 and 16 prior to treatment and the day after, Disp-50 tab, R-0, starting
S, E-Prescribe
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab and bortezomib for 270 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab and bortezomib for 270 minutes.
Day 4, Cycle 2 – Planned for 10/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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 3:46:57 PM Page 12 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 13 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 2 – Planned for 10/22/2017
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 14 of 56
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: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
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 10/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 15 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 16 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 11/2/2017 through 11/22/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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, Routine
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 17 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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
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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 18 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 4, 5, 8, 9, 11, 12, 15 and 16 prior to treatment and the day after, Disp-50 tab, R-0, starting S, E-Prescribe
Follow-Up
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 3:46:57 PM Page 19 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab and bortezomib for 270 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab and bortezomib for 270 minutes.
Day 4, Cycle 3 – Planned for 11/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 20 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): dexamethasone (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 8, Cycle 3 – Planned for 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 21 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 3 – Planned for 11/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 22 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 23 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 24 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 11/23/2017 through 12/13/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 11/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 25 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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
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.
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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 26 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 4, 5, 8, 9, 11 and 12 prior to treatment and the day after, Disp-40 tab, R-0, starting S, E-Prescribe
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
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 3:46:57 PM Page 27 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab and bortezomib for 270 minutes.
Day 4, Cycle 4 – Planned for 11/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 11/30/2017
Treatment Plan Information
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 28 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 4 – Planned for 12/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 29 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 12/14/2017 through 1/3/2018 (21 days), Planned
Day 1, Cycle 5 – Planned for 12/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 30 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+11 Approximate, Expires-S+365, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+11 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+11 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 31 of 56
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.
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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Take Home Medications
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 32 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 4, 5, 8, 9, 11 and 12 prior to treatment and the day after, Disp-40 tab, R-0, starting S,
E-Prescribe
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab and bortezomib for 270 minutes.
Day 4, Cycle 5 – Planned for 12/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
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 3:46:57 PM Page 33 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 5 – Planned for 12/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 34 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 5 – Planned for 12/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 1/4/2018 through 1/24/2018 (21 days), Planned
Day 1, Cycle 6 – Planned for 1/4/2018
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 35 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+11 Approximate, Expires-S+365, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+11 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+11 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 36 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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
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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
daratumumab (DARZALEX) 16 mg/kg in sodium chloride 0.9 % 500 mL bag
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 37 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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).
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 4, 5, 8, 9, 11 and 12 prior to treatment and the day after, Disp-40 tab, R-0, starting S, E-Prescribe
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab and bortezomib for 270 minutes.
Day 4, Cycle 6 – Planned for 1/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order 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 3:46:57 PM Page 38 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 – Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 39 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 6 – Planned for 1/14/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 40 of 56
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 1/25/2018 through 2/14/2018 (21 days), Planned
Day 1, Cycle 7 – Planned for 1/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+11 Approximate, Expires-S+365, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+11 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+11 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 41 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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 3:46:57 PM Page 42 of 56
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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 4, 5, 8, 9, 11 and 12 prior to treatment and the day after, Disp-40 tab, R-0, starting S, E-Prescribe
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab and bortezomib for 270 minutes.
Day 4, Cycle 7 – Planned for 1/28/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
IV Access
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 3:46:57 PM Page 43 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 7 – Planned for 2/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 44 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 7 – Planned for 2/4/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
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.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 45 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 2/15/2018 through 3/7/2018 (21 days), Planned
Day 1, Cycle 8 – Planned for 2/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+11 Approximate, Expires-S+365, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Routine
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 46 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CREATININE
Expected-S+11 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+11 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+11 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 47 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs on Day 1, 2, 4, 5, 8, 9, 11 and 12 prior to treatment and the day after, Disp-40 tab, R-0, starting S, E-Prescribe
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
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 3:46:57 PM Page 48 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin. CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
Day 4, Cycle 8 – Planned for 2/18/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 8 – Planned for 2/22/2018
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 49 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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 Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 8 – Planned for 2/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
IV Access
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 50 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE PRN Starting when released Until Discontinued, omit if taken at home
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 9 – 3/8/2018 through 4/4/2018 (28 days), Planned
Day 1, Cycle 9 – Planned for 3/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 51 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+11 Approximate, Expires-S+365, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+11 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+11 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 52 of 56
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.
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
Pre-Medications (delete all that do not apply)
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 chemotherapy. For use in patients who did not take dexamethasone at home.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to chemotherapy. For use in patients who did not take dexamethasone at home.
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
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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 53 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Take 3 tabs by mouth in AM of remaining doses of chemo then 1 tab daily on 1st and 2nd day after each chemo,
Disp-30 tab, R-5, starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin. CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
Cycle 10 – 4/5/2018 through 5/2/2018 (28 days), Planned
Day 1, Cycle 10 – Planned for 4/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Relapsed); THERAPY: dexamethasone 20 mg by mouth Day 1 (IV on Cycle 1 Day 1), 2, 4, 5, 8, 9, 11
and 12, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1, 8, and 15; CYCLE LENGTH: 21
days; COURSE: 3 cycles followed by THERAPY: dexamethasone 20 mg by mouth Day 1, 2, 4, 5, 8, 9, 11 and 12, bortezomib 1.3
mg/m2 subcutaneous Day 1, 4, 8 and 11, daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed
by THERAPY: daratumumab 16 mg/kg IV Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Patient also will receive 20 mg dexamethasone by mouth on day 15 and 16 for cycles 1-3 as part of concomitant medication
recommendations for daratumumab infusion.
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 54 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity 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
Pre-Medications (delete all that do not apply)
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 chemotherapy. For use in patients who did not take dexamethasone at home.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 55 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, if PO not taken at home
Administer 60 minutes prior to chemotherapy. For use in patients who did not take dexamethasone at home.
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
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.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Creatinine, BUN, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin. CHEMOTHERAPY ROOM APPOINTMENT:
daratumumab for 270 minutes.
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Zztestonc,Ondra O [2507491]
9/21/2017 3:46:57 PM Page 56 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org