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/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/name-96915-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 Dexamethasone(28D:1,8,15,22) Pomalidomide(28D:1-28) VER 10-3-16 (HL 5045)

CSC HEM Dexamethasone(28D:1,8,15,22) Pomalidomide(28D:1-28) VER 10-3-16 (HL 5045) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM DEXAMETHASONE(28D:1,8,15,22)/POMALIDOMIDE(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 (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
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)
MULTIPLE MYELOMA: Blade' J, et al. Br J Haematol 1998;102(5):1115-23.
Reference Information (2)
MULTIPLE MYELOMA: San Miguel J et al. Lancet Oncol. 2013;14(11):1055-66.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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 (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 without DIFF, ANC, Urine Pregnancy (women of childbearing potential)
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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., Disp-40 tab, R-0, starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

LABS: Urine Pregnancy (women of childbearing potential)
DAY 15 FOLLOW-UP
LABS: Urine Pregnancy (women of childbearing potential)
DAY 22 FOLLOW-UP
LABS: Urine Pregnancy (women of childbearing potential)
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider, LABS: CBC (DIFF if to be done locally), ANC, Urine
Pregnancy (women of childbearing potential)
Day 8 - Lab Day Only, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Day Only, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 - Lab Day Only, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urine Pregnancy (women of childbearing potential)
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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., Disp-40 tab, 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 (DIFF if to be done locally), ANC, Urine
Pregnancy (women of childbearing potential)
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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, Urine Pregnancy (women of childbearing potential)
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., Disp-40 tab, 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 (DIFF if to be done locally), ANC, Urine
Pregnancy (women of childbearing potential)
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 (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urine Pregnancy (women of childbearing potential)
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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., Disp-40 tab, 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 (DIFF if to be done locally), ANC, Urine
Pregnancy (women of childbearing potential)
Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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, Urine Pregnancy (women of childbearing potential)
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

dexamethasone (DECADRON) 4 MG tab
Take *** tablets by mouth once on Day 1, 8, 15, and 22., Disp-40 tab, 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 (DIFF if to be done locally), ANC, Urine
Pregnancy (women of childbearing potential)
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 (For patients 75 years old or younger): pomalidomide 4 mg by mouth daily on
Days 1 to 21, dexamethasone 40 mg by mouth on Days 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Thrombosis prophylaxis recommended for all patients.
Treatment Plan Summary (2)
DISEASE: Multiple Myeloma (Advanced); THERAPY (For patients older than 75 years): pomalidomide 4 mg by mouth daily on Days
1 to 21, dexamethasone 20 mg by mouth on Days 1, 8, 15, 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urine Pregnancy (women of childbearing potential)
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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., Disp-40 tab, 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 (DIFF if to be done locally), ANC, Urine
Pregnancy (women of childbearing potential)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:17:24 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