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CSC Lung Brigatinib(28D:1-28) VER 7-19-17 (HL 6504)

CSC Lung Brigatinib(28D:1-28) VER 7-19-17 (HL 6504) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG BRIGATINIB(28D:1-28) VER: 7-19-17 – Properties
Pre-Cycle – 7/12/2017 through 7/18/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 7/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: NSCLC (Advanced, ALK-positive); THERAPY: brigatinib 90 mg by mouth once daily Day 1 through 7 followed by
brigatinib 180 mg by mouth once daily Day 8 through 28; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
brigatinib 180 mg by mouth once daily Day 1 through 28 continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Chemotherapy Council approved for ALK-positive patients who have failed crizotinib.
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.
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
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
CK, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Cycle 1 – 7/19/2017 through 8/15/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 7/19/2017
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Zztestonc,Jeff J [2507481]
7/19/2017 9:20:36 AM Page 1 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
ALK+ NSCLC: Kim DW, et al. J Clin Oncol 2016; DOI: 10.1200/JCO.2016.71.5904.
Treatment Plan Summary
DISEASE: NSCLC (Advanced, ALK-positive); THERAPY: brigatinib 90 mg by mouth once daily Day 1 through 7 followed by
brigatinib 180 mg by mouth once daily Day 8 through 28; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
brigatinib 180 mg by mouth once daily Day 1 through 28 continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Chemotherapy Council approved for ALK-positive patients who have failed crizotinib.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Glucose, Amylase, Lipase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Glucose greater than 250 mg/dL or Amylase greater than 2 X ULN or Lipase
greater than 2 X ULN or Total CK greater than 5 X ULN or Heart Rate less than 60 bpm or Blood Pressure greater than 160/100
mmHg.
Nursing Procedure, Assessment and Monitoring
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Heart Rate and Blood Pressure.
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: brigatinib (dispensed Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications
brigatinib (ALUNBRIG) 30 MG tab
Take 3 tabs by mouth one time daily. For initiation of first 7 days of treatment., 90 mg, Disp-21 tab, R-0, 1 X DAILY starting S, Local
Printer
brigatinib (ALUNBRIG) 30 MG tab
Take 6 tabs by mouth one time daily. Begin after 7-day initiation therapy., 180 mg, Disp-180 tab, R-0, 1 X DAILY starting S, Local
Printer
Follow-Up
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Zztestonc,Jeff J [2507481]
7/19/2017 9:20:36 AM Page 2 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider: Blood Pressure measurement and pulmonary toxicity evaluation.
DAY 29 FOLLOW-UP
(Day 1 of the next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, BUN, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Amylase, Lipase, Total CK.
Cycle 2 – 8/16/2017 through 9/12/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: NSCLC (Advanced, ALK-positive); THERAPY: brigatinib 90 mg by mouth once daily Day 1 through 7 followed by
brigatinib 180 mg by mouth once daily Day 8 through 28; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by THERAPY:
brigatinib 180 mg by mouth once daily Day 1 through 28 continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression. NOTE: Chemotherapy Council approved for ALK-positive patients who have failed crizotinib.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+28 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+28 Approximate, Expires-S+365, Routine
CK, TOTAL
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Zztestonc,Jeff J [2507481]
7/19/2017 9:20:36 AM Page 3 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

Expected-S+28, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Glucose, Amylase, Lipase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Glucose greater than 250 mg/dL or Amylase greater than 2 X ULN or Lipase
greater than 2 X ULN or Total CK greater than 5 X ULN or Heart Rate less than 60 bpm or Blood Pressure greater than 160/100
mmHg.
Nursing Procedure, Assessment and Monitoring
Vital Signs
SEE COMMENTS Starting when released Until Specified
Obtain Heart Rate and Blood Pressure.
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
Oral Chemotherapy Order Management
For this regimen, brigatinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of the next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, BUN, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Amylase, Lipase, Total CK.
Cycle 3 – 9/13/2017 through 10/10/2017 (28 days), Planned
Cycle 4 – 10/11/2017 through 11/7/2017 (28 days), Planned
Cycle 5 – 11/8/2017 through 12/5/2017 (28 days), Planned
Cycle 6 – 12/6/2017 through 1/2/2018 (28 days), Planned
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Zztestonc,Jeff J [2507481]
7/19/2017 9:20:36 AM Page 4 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org