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/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/name-96914-en.cckm

201611326

page

100

UWHC,UWMF,

Tools,

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

CSC HEM Cyclophosphamide(28D:1,8) Dexamethasone(28D:1-4,8-11) Lenalidomide(28D:1-21) VER 10-3-16 (HL 4947)

CSC HEM Cyclophosphamide(28D:1,8) Dexamethasone(28D:1-4,8-11) Lenalidomide(28D:1-21) VER 10-3-16 (HL 4947) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM CYCLOPHOSPHAMIDE (ORAL) (28D:1,8)/DEXAMETHASONE(28D:1-4,8-11)/LENALIDOMIDE(28D:1-21) VER: 10-3-
16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: lenalidomide 25 mg by mouth once daily Days 1 through 21, dexamethasone
20 mg by mouth once daily Days 1 through 4 and Days 8 through 11, cyclophosphamide 600 mg by mouth Day 1 and 8; 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
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 2 tab orally before cyclophosphamide Day 1 & 8 and 1 tab every 8h as needed for nausea., Disp-30 tab, R-5, starting S
Take Home Medications (delete all that do not apply)
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
aspirin 325 MG EC tab
Take 1 tab by mouth one time daily., 325 mg, Disp-30 tab, R-11, 1 X DAILY starting S
enoxaparin (LOVENOX) 40 MG/0.4ML injection
Inject 40 mg under skin one time daily., 40 mg, Disp-30 Syringe, R-11, 1 X DAILY starting S
warfarin (COUMADIN) 5 MG tab
Take 1 tab by mouth one time daily at bedtime., 5 mg, Disp-30 tab, R-11, 1 X DAILY (HS) starting S
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Schey SA, et al. Br J Haematol 2010;150:326-33
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 1 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (2)
MYELOMA: Morgan GJ, et al. Br J Haematol 2007;137:268-9
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: lenalidomide 25 mg by mouth once daily Days 1 through 21, dexamethasone
20 mg by mouth once daily Days 1 through 4 and Days 8 through 11, cyclophosphamide 600 mg by mouth Day 1 and 8; 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 (delete all that do not apply)
HCG, QUALITATIVE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
Remind patient to take ondansetron 30 minutes prior to taking cyclophosphamide on Days 1 and 8.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (Dispensed on Day 1 of every
cycle), dexamethasone (Dispensed on Day 1 of every cycle), cyclophosphamide (Dispensed on Day 1 of every cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
lenalidomide (REVLIMID) 25 MG cap
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 2 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 1 cap by mouth one time daily. Take by mouth on Days 1 through 21 of cycle., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S,
Local Printer
Verify compliance with the Revlimid program. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take by mouth once daily on Days 1 through 4 and Days 8 through 11 of the cycle., 20 mg,
Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 12 caps by mouth one time daily. Take by mouth once daily on Days 1 and 8 of the Cycle., 600 mg, Disp-24 cap, R-0, 1 X
DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Electrolytes, Creatinine,
Glucose. NOTE: Urine Pregnancy test to be ordered by MD when required.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: lenalidomide 25 mg by mouth once daily Days 1 through 21, dexamethasone
20 mg by mouth once daily Days 1 through 4 and Days 8 through 11, cyclophosphamide 600 mg by mouth Day 1 and 8; CYCLE
LENGTH: 28 days; COURSE: until disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 3 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of
childbearing potential with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
Remind patient to take ondansetron 30 minutes prior to taking cyclophosphamide on Days 1 and 8.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (Dispensed on Day 1 of every
cycle), dexamethasone (Dispensed on Day 1 of every cycle), cyclophosphamide (Dispensed on Day 1 of every cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take by mouth on Days 1 through 21 of cycle., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S,
Local Printer
Verify compliance with the Revlimid program. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take by mouth once daily on Days 1 through 4 and Days 8 through 11 of the cycle., 20 mg,
Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 12 caps by mouth one time daily. Take by mouth once daily on Days 1 and 8 of the Cycle., 600 mg, Disp-24 cap, R-0, 1 X
DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Electrolytes, Creatinine,
Glucose. NOTE: Urine Pregnancy test to be ordered by MD when required.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: lenalidomide 25 mg by mouth once daily Days 1 through 21, dexamethasone
20 mg by mouth once daily Days 1 through 4 and Days 8 through 11, cyclophosphamide 600 mg by mouth Day 1 and 8; CYCLE
LENGTH: 28 days; COURSE: until disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 4 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
Remind patient to take ondansetron 30 minutes prior to taking cyclophosphamide on Days 1 and 8.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (Dispensed on Day 1 of every
cycle), dexamethasone (Dispensed on Day 1 of every cycle), cyclophosphamide (Dispensed on Day 1 of every cycle).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 5 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take by mouth on Days 1 through 21 of cycle., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S,
Local Printer
Verify compliance with the Revlimid program. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take by mouth once daily on Days 1 through 4 and Days 8 through 11 of the cycle., 20 mg,
Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 12 caps by mouth one time daily. Take by mouth once daily on Days 1 and 8 of the Cycle., 600 mg, Disp-24 cap, R-0, 1 X
DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Electrolytes, Creatinine,
Glucose. NOTE: Urine Pregnancy test to be ordered by MD when required.
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: lenalidomide 25 mg by mouth once daily Days 1 through 21, dexamethasone
20 mg by mouth once daily Days 1 through 4 and Days 8 through 11, cyclophosphamide 600 mg by mouth Day 1 and 8; CYCLE
LENGTH: 28 days; COURSE: until disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 6 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
Remind patient to take ondansetron 30 minutes prior to taking cyclophosphamide on Days 1 and 8.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (Dispensed on Day 1 of every
cycle), dexamethasone (Dispensed on Day 1 of every cycle), cyclophosphamide (Dispensed on Day 1 of every cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take by mouth on Days 1 through 21 of cycle., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S,
Local Printer
Verify compliance with the Revlimid program. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take by mouth once daily on Days 1 through 4 and Days 8 through 11 of the cycle., 20 mg,
Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 12 caps by mouth one time daily. Take by mouth once daily on Days 1 and 8 of the Cycle., 600 mg, Disp-24 cap, R-0, 1 X
DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Electrolytes, Creatinine,
Glucose. NOTE: Urine Pregnancy test to be ordered by MD when required.
Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 7 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Multiple Myeloma (Advanced); THERAPY: lenalidomide 25 mg by mouth once daily Days 1 through 21,
dexamethasone 20 mg by mouth once daily Days 1 through 4 and Days 8 through 11, cyclophosphamide 600 mg
by mouth Day 1 and 8; CYCLE LENGTH: 28 days; COURSE: until disease progression. NOTE: Thrombosis
prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
Remind patient to take ondansetron 30 minutes prior to taking cyclophosphamide on Days 1 and 8.
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,Andrew [2428787]
11/21/2016 1:54:29 PM Page 8 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (Dispensed on Day 1 of every
cycle), dexamethasone (Dispensed on Day 1 of every cycle), cyclophosphamide (Dispensed on Day 1 of every cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take by mouth on Days 1 through 21 of cycle., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S,
Local Printer
Verify compliance with the Revlimid program. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take by mouth once daily on Days 1 through 4 and Days 8 through 11 of the cycle., 20 mg,
Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 12 caps by mouth one time daily. Take by mouth once daily on Days 1 and 8 of the Cycle., 600 mg, Disp-24 cap, R-0, 1 X
DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Electrolytes, Creatinine,
Glucose. NOTE: Urine Pregnancy test to be ordered by MD when required.
Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: lenalidomide 25 mg by mouth once daily Days 1 through 21, dexamethasone
20 mg by mouth once daily Days 1 through 4 and Days 8 through 11, cyclophosphamide 600 mg by mouth Day 1 and 8; CYCLE
LENGTH: 28 days; COURSE: until disease progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 9 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
Remind patient to take ondansetron 30 minutes prior to taking cyclophosphamide on Days 1 and 8.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (Dispensed on Day 1 of every
cycle), dexamethasone (Dispensed on Day 1 of every cycle), cyclophosphamide (Dispensed on Day 1 of every cycle).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take by mouth on Days 1 through 21 of cycle., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S,
Local Printer
Verify compliance with the Revlimid program. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take by mouth once daily on Days 1 through 4 and Days 8 through 11 of the cycle., 20 mg,
Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 12 caps by mouth one time daily. Take by mouth once daily on Days 1 and 8 of the Cycle., 600 mg, Disp-24 cap, R-0, 1 X
DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Electrolytes, Creatinine,
Glucose. NOTE: Urine Pregnancy test to be ordered by MD when required.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 10 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ZZtestonc,Andrew [2428787]
11/21/2016 1:54:29 PM Page 11 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org