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201712342

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CSC Hem Daratumumab(28D)/Dexamethasone(28D:1,8,15,22)/Pomalidomide(28D:1-21) VER 12-8-17 (HL 6093)

CSC Hem Daratumumab(28D)/Dexamethasone(28D:1,8,15,22)/Pomalidomide(28D:1-21) VER 12-8-17 (HL 6093) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM DARATUMUMAB(28D)/DEXAMETHASONE(28D:1,8,15,22)/POMALIDOMIDE(28D:1-21) VER: 12-8-
17 –  Properties
Pre-Cycle –  12/1/2017 through 12/7/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 12/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
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
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 1 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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
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.
famotidine (PEPCID) 20 MG tab
Take 1 tab by mouth 2 times daily., 20 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
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
diphenhydramine (BENADRYL) 25 MG cap
Take 1 to 2 capsules by mouth as needed for infusion reaction (may occur up to 4 hours after infusion ends). Available
over-the-counter., Disp-30 cap, R-1, starting S, Local Printer
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
Take Home Medications (delete all that do not apply)
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
aspirin EC 325 MG delayed release tab
Take 1 tab by mouth one time daily., 325 mg, Disp-30 tab, R-11, 1 X DAILY starting S
enoxaparin (LOVENOX) 40 MG/0.4ML injection
Inject 40 mg under skin one time daily., 40 mg, Disp-30 Syringe, R-11, 1 X DAILY starting S
warfarin (COUMADIN) 5 MG tab
Take 1 tab by mouth one time daily at bedtime., 5 mg, Disp-30 tab, R-11, 1 X DAILY (HS) starting S
Cycle 1 –  12/8/2017 through 1/4/2018 (28 days), Planned
Day 1, Cycle 1 –  Planned for 12/8/2017
Treatment Plan Information
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...
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,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 2 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Reference Information (1)
MULTIPLE MYELOMA: Chari A, et al.  508 Open-Label, Multicenter, Phase 1b Study of Daratumumab in Combination
with Pomalidomide and Dexamethasone in Patients with at Least 2 Lines of Prior Therapy and Relapsed or Relapsed and
Refractory Multiple Myeloma.  Abstract presented at: 57th Annual Meeting of the American Society of Hematology;
December 7th, 2015; Orlando, FL.
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X ULN or AST greater than or equal to
3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline Phosphatase greater than or equal to 3.5 X ULN or
Total Bilirubin greater than or equal to 2.5 mg/dL.
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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 3 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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.
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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 4 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: Pregnancy Test (for women of child-bearing potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab
for 390 minutes.
DAY 15 FOLLOW-UP
LABS: Pregnancy Test (for women of child-bearing potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab
for 270 minutes.
DAY 22 FOLLOW-UP
LABS: Pregnancy Test (for women of child-bearing potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab
for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Creatinine, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 8, Cycle 1 –  Planned for 12/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 5 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+7 Approximate, Expires: S+365, Routine
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,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 6 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and 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 12/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 7 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+7 Approximate, Expires: S+365, Routine
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.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 8 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and 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 22, Cycle 1 –  Planned for 12/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 9 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+7 Approximate, Expires: S+365, Routine
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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 10 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and 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 –  1/5/2018 through 2/1/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 1/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 11 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
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
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 12 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less
than or equal to 75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X
ULN or AST greater than or equal to 3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline
Phosphatase greater than or equal to 3.5 X ULN or Total Bilirubin greater than or equal to 2.5 mg/dL.
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
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 infusion. For use in patients who did not take dexamethasone at home.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 13 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Take Home Medications (delete all that do not apply)
pomalidomide (POMALYST) 1 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 1 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 2 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 2 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 3 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 3 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 14 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Glucose, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 8, Cycle 2 –  Planned for 1/12/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 15 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Allow infusion to come to room temperature prior to administration. Administer with a 0.2 or 0.22 micrometer filter.
First infusion (in 1000mL): initial infusion rate is 50mL/hr. If no infusion reactions, may increase rate by 50mL/hr every
hour to a maximum rate of 200mL/hr.
Second infusion (in 500mL): Infuse at 50mL/hr for the first hour. Escalate the rate only if there were no grade 1 (mild) or
greater infusion reactions during the first 3 hours of the first infusion. If no infusion reaction occurs, escalate the rate by
50mL/hr every hour to a maximum rate of 200mL/hr.
Subsequent infusions (in 500mL): Infuse at 100mL/hr. Escalate only if there were no Grade 1 (mild) or greater infusion
reactions during a final infusion rate of >/= 100mL/hour in the first two infusions. Escalate by 50 mL/hr every hour to a
maximum rate of 200mL/hr.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 16 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): pomalidomide
(dispensed day 1 of each cycle) and 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 1/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 17 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 18 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 –  Planned for 1/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 19 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Follow-Up
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 20 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  2/2/2018 through 3/1/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 2/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 21 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X ULN or AST greater than or equal to
3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline Phosphatase greater than or equal to 3.5 X ULN or
Total Bilirubin greater than or equal to 2.5 mg/dL.
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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 22 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Take Home Medications (delete all that do not apply)
pomalidomide (POMALYST) 1 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 1 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 2 MG cap
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 23 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 2 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 3 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 3 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Creatinine, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 3 –  Planned for 2/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 24 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. For use in patients who did not take dexamethasone at home.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 25 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and 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 –  3/2/2018 through 3/29/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 3/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 26 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X ULN or AST greater than or equal to
3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline Phosphatase greater than or equal to 3.5 X ULN or
Total Bilirubin greater than or equal to 2.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 27 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. For use in patients who did not take dexamethasone at home.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 28 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Take Home Medications (delete all that do not apply)
pomalidomide (POMALYST) 1 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 1 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 2 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 2 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 3 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 3 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 29 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Creatinine, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 4 –  Planned for 3/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 30 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 31 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and 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 –  3/30/2018 through 4/26/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 3/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 32 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X ULN or AST greater than or equal to
3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline Phosphatase greater than or equal to 3.5 X ULN or
Total Bilirubin greater than or equal to 2.5 mg/dL.
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,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 33 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 34 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Take Home Medications (delete all that do not apply)
pomalidomide (POMALYST) 1 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 1 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 2 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 2 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 3 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 3 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Creatinine, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 5 –  Planned for 4/13/2018
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 35 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 36 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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.
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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 37 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and 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 –  4/27/2018 through 5/24/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/27/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 38 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X ULN or AST greater than or equal to
3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline Phosphatase greater than or equal to 3.5 X ULN or
Total Bilirubin greater than or equal to 2.5 mg/dL.
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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 39 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 40 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Take Home Medications (delete all that do not apply)
pomalidomide (POMALYST) 1 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 1 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 2 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 2 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 3 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 3 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Creatinine, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Day 15, Cycle 6 –  Planned for 5/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 41 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75
years): daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1
through 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days;
COURSE: 2 cycles followed by THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4
mg by mouth daily on Days 1 through 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22;
CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by THERAPY: daratumumab 16 mg/kg IV Day 1,
pomalidomide 4 mg by mouth daily on Days 1 through 21, dexamethasone 20 mg by mouth on Days
1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease progression.  NOTE: Thrombosis
prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 42 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and 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.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 43 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Cycle 7 –  5/25/2018 through 6/21/2018 (28 days), Planned
Day 1, Cycle 7 –  Planned for 5/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 44 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

HCG, QUALITATIVE, URINE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X ULN or AST greater than or equal to
3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline Phosphatase greater than or equal to 3.5 X ULN or
Total Bilirubin greater than or equal to 2.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to daratumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Monitor vital signs every 30 minutes.
Patient Instructions(1)
Patient should pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 45 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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.
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
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 46 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Take Home Medications (delete all that do not apply)
pomalidomide (POMALYST) 1 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 1 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 2 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 2 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 3 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 3 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Creatinine, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
Cycle 8 –  6/22/2018 through 7/19/2018 (28 days), Planned
Day 1, Cycle 8 –  Planned for 6/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients 75 years old or younger without diabetes):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 40 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Refractory); THERAPY (for patients with diabetes or patients older than 75 years):
daratumumab 16 mg/kg IV Days 1, 8, 15 and 22, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 2 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Days 1 and 15, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles followed by
THERAPY: daratumumab 16 mg/kg IV Day 1, pomalidomide 4 mg by mouth daily on Days 1 through 21,
dexamethasone 20 mg by mouth on Days 1, 8, 15, and 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression.  NOTE: Thrombosis prophylaxis recommended for all patients.
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
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 47 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
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
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin and Pregnancy Test (for women of child-bearing potential).
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
75K/uL or Hemoglobin less than or equal to 7.5 g/dL or Creatinine greater than 2 X ULN or AST greater than or equal to
3.5 X ULN or ALT greater than or equal to 3.5 X ULN, or Alkaline Phosphatase greater than or equal to 3.5 X ULN or
Total Bilirubin greater than or equal to 2.5 mg/dL.
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,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 48 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 60 minutes prior to start of infusion.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
No more than 4 grams acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 4 HOURS PRN, 2 doses Starting when released, to prevent infusion reactions
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 infusion. 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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 49 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
daratumumab (DARZALEX) 1,200 mg in sodium chloride 0.9 % 500 mL bag
1,200 mg (rounded from 1,280 mg = 16 mg/kg × 80 kg Treatment plan recorded weight), 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 medication section for the following treatment medication(s): pomalidomide (dispensed day 1
of each cycle) and dexamethasone (dispensed day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., R-0, starting S, Local Printer
Take Home Medications (delete all that do not apply)
pomalidomide (POMALYST) 1 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 1 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 2 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 2 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 3 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 3 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
pomalidomide (POMALYST) 4 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 21, then 7 days off. Swallow whole; do not break, chew, or open
the capsules., 4 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Pomalyst REMS. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Electrolytes,
Creatinine, Glucose, AST, ALT, Alkaline Phosphatase, Total Bilirubin, and Pregnancy Test (for women of child-bearing
potential); CHEMOTHERAPY ROOM APPOINTMENT: daratumumab for 270 minutes.
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Zztestonc,Jeff J [2507481]
12/8/2017 10:55:36 AM Page 50 of 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org