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CSC HEM Cytarabine(28-42D:1,3,5)/Midostaurin(28-42D:8-21) Outpatient 3 Short Stays Ver 12-5-17 (HL 6528)

CSC HEM Cytarabine(28-42D:1,3,5)/Midostaurin(28-42D:8-21) Outpatient 3 Short Stays Ver 12-5-17 (HL 6528) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM CYTARABINE(28-42D:1,3,5)/MIDOSTAURIN(28-42D:8-21) OUTPATIENT 3 SHORT STAYS VER: 12-5-
17 –  Properties
Cycle 1 –  12/5/2017 through 1/1/2018 (28 days), Planned
Day 1, Cycle 1 –  Planned for 12/5/2017
Treatment Plan Information
Reference Information (1)
ACUTE MYELOGENOUS LEUKEMIA: RYDAPT [package insert]. East Hanover, NJ: Novartis; 2017.
Reference Information (2)
ACUTE MYELOGENOUS LEUKEMIA: Stone RM, et al. N Engl J Med 2017;377(5):454-64.
Treatment Plan Summary
DISEASE: FLT3(+) Acute Myelogenous Leukemia; THERAPY: cytarabine 3000 mg/m2 IV every 12 hours Day 1, 3 and 5
(Total of 6 doses/cycle), midostaurin 50 mg by mouth twice daily Day 8 through 21; CYCLE LENGTH: 28 to 42 days;
COURSE: up to 4 cycles
Note to All Staff
Consider cytarabine dose reduction to 1500 mg/m2 for patients who have 2 of the following 3 criteria: Age greater than
40 years old; Creatinine greater than or equal to 1.2 mg/dL; and/or 3 fold increase Alkaline Phosphatase. Dose
reduction to 1000 mg/m2 or 1500 mg/m2 for all patients greater than 60 years old.
Note to All Staff (2)
Discontinue midostaurin if signs/symptoms of interstitial lung disease or pneumonitis without infectious etiology.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC with DIFF, Creatinine, Alkaline Phosphatase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Creatinine greater than 1.2 mg/dL or Alkaline Phosphatase greater
than 3 X ULN.
Treatment Condition A
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Zztestonc,Fiona F [2462287]
12/5/2017 8:29:23 AM Page 1 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Verify ECG obtained one week following the start of midostaurin.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of cytarabine
and as needed.  For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or Staff on
call.
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, CONTINUOUS Starting when released Until Discontinued
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released, nausea/vomiting
Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to first dose of cytarabine. May give IV if PO not tolereated.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting when released
Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), EVERY 6 HOURS, 16 doses Starting when released
Day 1: Instill one drop into each eye 4 times a day. First dose prior to chemotherapy.
Patient to continue to use this bottle for remainder of therapy and RN to verify patient administration.
Treatment Medications
cytarabine PF (CYTOSAR) 3,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
3,000 mg/m2, Intravenous, EVERY 12 HOURS, 2 doses Starting when released
Administer over 3 hours.
See Take Home Medication(s)
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Zztestonc,Fiona F [2462287]
12/5/2017 8:29:23 AM Page 2 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): midostaurin (Dispensed Day 1 of
each cycle).
Supportive Care Medications
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
famotidine (PEPCID) tab 20 mg
20 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 200 mg
200 mg, Oral, 1 X DAILY Starting when released
Continue until ANC greater than 500/µL after nadir.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
Take Home Medications
midostaurin (RYDAPT) 25 MG cap
Take 2 caps by mouth 2 times daily. Days 8 through 21. Take with food at approximately 12-hour intervals., 50 mg,
Disp-56 cap, R-0, 2 X DAILY starting S, E-Prescribe
ondansetron (ZOFRAN) 4 MG tab
Take 2 tabs by mouth every 8 hours as needed. Take 2 tabs twice daily Days 2, 4, 6, 7 & 1 tab twice daily prior to
midostaurin Days 8-21, 8 mg, Disp-50 tab, R-0, EVERY 8 HOURS PRN starting S, E-Prescribe
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Follow-Up
DAY 3 FOLLOW-UP
Admit to B6/6 (short stay observation)
DAY 5 FOLLOW-UP
Admit to B6/6 (short stay observation)
DAY 29 FOLLOW-UP
(Day 1 of next cycle): Admit to B6/6 (short stay observation)
Day 3, Cycle 1 –  Planned for 12/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: FLT3(+) Acute Myelogenous Leukemia; THERAPY: cytarabine 3000 mg/m2 IV every 12 hours Day 1, 3 and 5
(Total of 6 doses/cycle), midostaurin 50 mg by mouth twice daily Day 8 through 21; CYCLE LENGTH: 28 to 42 days;
COURSE: up to 4 cycles
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: Pharmacy   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: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
12/5/2017 8:29:23 AM Page 3 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Note to All Staff
Consider cytarabine dose reduction to 1500 mg/m2 for patients who have 2 of the following 3 criteria:
Age greater than 40 years old; Creatinine greater than or equal to 1.2 mg/dL; and/or 3 fold increase
Alkaline Phosphatase. Dose reduction to 1000 mg/m2 or 1500 mg/m2 for all patients greater than 60
years old.
Note to All Staff (2)
Discontinue midostaurin if signs/symptoms of interstitial lung disease or pneumonitis without infectious etiology.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of cytarabine
and as needed.  For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or Staff on
call.
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, CONTINUOUS Starting when released Until Discontinued
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released, nausea/vomiting
Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to first dose of cytarabine. May give IV if PO not tolereated.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting when released
Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), EVERY 6 HOURS, 16 doses Starting when released
Day 3 and 5: Instill one drop into each eye 4 times a day. First dose prior to chemotherapy. Use patient's own supply.
Patient to continue to use this bottle for remainder of therapy and RN to verify patient administration.
Treatment Medications
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Zztestonc,Fiona F [2462287]
12/5/2017 8:29:23 AM Page 4 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

cytarabine PF (CYTOSAR) 3,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
3,000 mg/m2, Intravenous, EVERY 12 HOURS, 2 doses Starting when released
Administer over 3 hours.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): midostaurin (Dispensed Day 1 of
each cycle).
Supportive Care Medications
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
famotidine (PEPCID) tab 20 mg
20 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 200 mg
200 mg, Oral, 1 X DAILY Starting when released
Continue until ANC greater than 500/µL after nadir.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 –  Planned for 12/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: FLT3(+) Acute Myelogenous Leukemia; THERAPY: cytarabine 3000 mg/m2 IV every 12 hours Day 1, 3 and 5
(Total of 6 doses/cycle), midostaurin 50 mg by mouth twice daily Day 8 through 21; CYCLE LENGTH: 28 to 42 days;
COURSE: up to 4 cycles
Note to All Staff
Consider cytarabine dose reduction to 1500 mg/m2 for patients who have 2 of the following 3 criteria: Age greater than
40 years old; Creatinine greater than or equal to 1.2 mg/dL; and/or 3 fold increase Alkaline Phosphatase. Dose
reduction to 1000 mg/m2 or 1500 mg/m2 for all patients greater than 60 years old.
Note to All Staff (2)
Discontinue midostaurin if signs/symptoms of interstitial lung disease or pneumonitis without infectious etiology.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of cytarabine
and as needed.  For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or Staff on
call.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Fiona F [2462287]
12/5/2017 8:29:23 AM Page 5 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released, nausea/vomiting
Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to first dose of cytarabine. May give IV if PO not tolereated.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting when released
Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), EVERY 6 HOURS, 16 doses Starting when released
Day 3 and 5: Instill one drop into each eye 4 times a day. First dose prior to chemotherapy. Use patient's own supply.
Patient to continue to use this bottle for remainder of therapy and RN to verify patient administration.
Treatment Medications
cytarabine PF (CYTOSAR) 3,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
3,000 mg/m2, Intravenous, EVERY 12 HOURS, 2 doses Starting when released
Administer over 3 hours.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): midostaurin (Dispensed Day 1 of
each cycle).
Supportive Care Medications
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
famotidine (PEPCID) tab 20 mg
20 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 200 mg
200 mg, Oral, 1 X DAILY Starting when released
Continue until ANC greater than 500/µL after nadir.
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Zztestonc,Fiona F [2462287]
12/5/2017 8:29:23 AM Page 6 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
12/5/2017 8:29:23 AM Page 7 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org