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201611326

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CSC HEM Dexamethasone(28D:1,8,15,22) Lenalidomide(28D:1-21) VER 10-3-16 (HL 1083)

CSC HEM Dexamethasone(28D:1,8,15,22) Lenalidomide(28D:1-21) VER 10-3-16 (HL 1083) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM DEXAMETHASONE(28D:1,8,15,22)/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: Myeloma; THERAPY: dexamethasone 40 mg by mouth Day 1, 8, 15 and 22, lenalidomide 25 mg by mouth daily Day 1
through Day 21; CYCLE LENGTH: 28 days; COURSE: 4 cycles or until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
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
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
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: Weber DM, et al. New Eng J Med 2007;357:2133-42.
Reference Information (2)
MYELOMA: Rajkumar SV, et al. Lancet Oncol 2010;11(1):29-37
Reference Information (3)
MYELOMA: Benboubker L, et al. N Engl J Med 2014;371(10):906-17
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: dexamethasone 40 mg by mouth Day 1, 8, 15 and 22, lenalidomide 25 mg by mouth daily Day 1
through Day 21; CYCLE LENGTH: 28 days; COURSE: 4 cycles or until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:16:12 PM Page 1 of 6
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

For patients greater than 75 years of age, start at lower lenalidomide dose.
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, ANC.
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)).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). 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
Reference Information (1)
MYELOMA: Weber DM, et al. New Eng J Med 2007;357:2133-42.
Reference Information (2)
MYELOMA: Rajkumar SV, et al. Lancet Oncol 2010;11(1):29-37
Reference Information (3)
MYELOMA: Benboubker L, et al. N Engl J Med 2014;371(10):906-17
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: dexamethasone 40 mg by mouth Day 1, 8, 15 and 22, lenalidomide 25 mg by mouth daily Day 1
through Day 21; CYCLE LENGTH: 28 days; COURSE: 4 cycles or until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:16:12 PM Page 2 of 6
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

For patients greater than 75 years of age, start at lower lenalidomide dose.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). 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
Reference Information (1)
MYELOMA: Weber DM, et al. New Eng J Med 2007;357:2133-42.
Reference Information (2)
MYELOMA: Rajkumar SV, et al. Lancet Oncol 2010;11(1):29-37
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ZZtestonc,Andrew [2428787]
11/21/2016 2:16:12 PM Page 3 of 6
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (3)
MYELOMA: Benboubker L, et al. N Engl J Med 2014;371(10):906-17
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: dexamethasone 40 mg by mouth Day 1, 8, 15 and 22, lenalidomide 25 mg by mouth daily Day 1
through Day 21; CYCLE LENGTH: 28 days; COURSE: 4 cycles or until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
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ZZtestonc,Andrew [2428787]
11/21/2016 2:16:12 PM Page 4 of 6
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Weber DM, et al. New Eng J Med 2007;357:2133-42.
Reference Information (2)
MYELOMA: Rajkumar SV, et al. Lancet Oncol 2010;11(1):29-37
Reference Information (3)
MYELOMA: Benboubker L, et al. N Engl J Med 2014;371(10):906-17
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: dexamethasone 40 mg by mouth Day 1, 8, 15 and 22, lenalidomide 25 mg by mouth daily Day 1
through Day 21; CYCLE LENGTH: 28 days; COURSE: 4 cycles or until disease progression. NOTE: Thrombosis prophylaxis
recommended for all patients.
Note to All Staff (1)
For patients greater than 75 years of age, start at lower lenalidomide dose.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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).
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and lenalidomide (dispensed Day 1 of each cycle)
Take Home Medications
lenalidomide (REVLIMID) 25 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 25 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with Revlimid REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8, 15 and 22., 40 mg, Disp-40 tab, R-0, EVERY 7 DAYS starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:16:12 PM Page 5 of 6
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:16:12 PM Page 6 of 6
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org