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CSC LUNG Dabrafenib(28D:1-28)/Trametinib(28D:1-28) Ver 9-7-17 (HL 6358)

CSC LUNG Dabrafenib(28D:1-28)/Trametinib(28D:1-28) Ver 9-7-17 (HL 6358) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG DABRAFENIB(28D:1-28)/TRAMETINIB(28D:1-28) VER: 9-7-17 –  Properties
Pre-Cycle –  8/31/2017 through 9/6/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Metastatic NSCLC (Advanced, BRAF V600E mutation); THERAPY: dabrafenib 150 mg by mouth twice daily
continuously, trametinib 2 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Trametinib is expected to cause fetal harm if administered to a pregnant woman. Women of childbearing potential
should use a highly effective contraceptive during therapy and for 4 months after treatment is complete.
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
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
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
Expected: S Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S Approximate, Expires: S+365, Routine
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 1 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected: S Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Condition A
Verify patient has obtained pretreatment ECG and MUGA or ECHO.
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Cycle 1 –  9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 9/7/2017
Treatment Plan Information
Reference Information (1)
NON SMALL CELL LUNG CANCER: Planchard D, et al. Lancet Oncol 2016;17:984-93.
Treatment Plan Summary
DISEASE: Metastatic NSCLC (Advanced, BRAF V600E mutation); THERAPY: dabrafenib 150 mg by mouth twice daily
continuously, trametinib 2 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Trametinib is expected to cause fetal harm if administered to a pregnant woman. Women of childbearing potential
should use a highly effective contraceptive during therapy and for 4 months after treatment is complete.
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 with DIFF, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for temperature greater than 101.3 F or ANC less than 1000/uL or
Creatinine rise of greater than 0.5 mg/dL above baseline or Creatinine greater than 2 mg/dL or Ejection Fraction less
than LLN.
Treatment Condition A
Verify patient has obtained pretreatment ECG and MUGA or ECHO.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 2 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Educate patient to take dabrafenib orally at least 1 hour before or 2 hours after a meal. Doses should be administered
approximately 12 hours apart. Do not open, crush, or break capsules. A missed dose may be administered up to 6 hours
prior to the next dose.
Educate patient to take trametinib 1 hour before or 2 hours after a meal. Do not take a missed dose within 12 hours of
the next dose. When taking in combination with dabrafenib, take the once daily trametinib dose at the same time each
day with either the morning or evening dose of dabrafenib.
Patient Instructions(2)
Educate patient regarding risk of diarrhea, rash, and visual disturbances due to trametinib.
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): dabrafenib and trametinib
(dispensed Day 1 of Cycle 1 only - subsequent refills will be ordered through the medication activity).
Take Home Medications
dabrafenib mesylate (TAFINLAR) 75 MG cap
Take 2 caps by mouth 2 times daily. Take on empty stomach, 1 hour before or 2 hours after meals. Do not open,
crush, or break caps., 150 mg, Disp-120 cap, R-0, 2 X DAILY starting S
trametinib dimethyl sulfoxide (MEKINIST) 2 MG tab
Take 1 tab by mouth one time daily. Take on empty stomach, 1 hour before or 2 hours after a meal., 2 mg, Disp-30
tab, R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH; PROCEDURE: ECG
and ECHO or MUGA.
Cycle 2 –  10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
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,Edward E [2435061]
9/7/2017 10:59:35 AM Page 3 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

DISEASE: Metastatic NSCLC (Advanced, BRAF V600E mutation); THERAPY: dabrafenib 150 mg by mouth twice daily
continuously, trametinib 2 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Trametinib is expected to cause fetal harm if administered to a pregnant woman. Women of childbearing potential
should use a highly effective contraceptive during therapy and for 4 months after treatment is complete.
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
GLUCOSE
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
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
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
LD, TOTAL
Expected: S+28 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 4 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for temperature greater than 101.3 F or ANC less than 1000/uL or
Creatinine rise of greater than 0.5 mg/dL above baseline or Creatinine greater than 2 mg/dL or Ejection Fraction less
than LLN.
Treatment Condition A
Verify patient has obtained pretreatment ECG and MUGA or ECHO obtained every 2 to 3 Cycles beginning Cycle 2.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for complaints of visual disturbances due to trametinib and need for ophthalmological evaluation.
Monitoring Parameters (2)
Monitor patient for signs and symptoms of pulmonary toxicity (cough, dyspnea, hypoxia, pleural effusion, or infiltrates)
due to trametinib.
Patient Instructions(1)
Educate patient to take dabrafenib orally at least 1 hour before or 2 hours after a meal. Doses should be administered
approximately 12 hours apart. Do not open, crush, or break capsules. A missed dose may be administered up to 6 hours
prior to the next dose.
Educate patient to take trametinib 1 hour before or 2 hours after a meal. Do not take a missed dose within 12 hours of
the next dose. When taking in combination with dabrafenib, take the once daily trametinib dose at the same time each
day with either the morning or evening dose of dabrafenib.
Patient Instructions(2)
Educate patient regarding risk of diarrhea, rash, and visual disturbances due to trametinib.
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, dabrafenib and trametinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH. PROCEDURE
(every other Cycle): ECG and ECHO or MUGA
Cycle 3 –  11/2/2017 through 11/29/2017 (28 days), Planned
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 5 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Day 1, Cycle 3 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Metastatic NSCLC (Advanced, BRAF V600E mutation); THERAPY: dabrafenib 150 mg by mouth twice daily
continuously, trametinib 2 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Trametinib is expected to cause fetal harm if administered to a pregnant woman. Women of childbearing potential
should use a highly effective contraceptive during therapy and for 4 months after treatment is complete.
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
GLUCOSE
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
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
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
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 6 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

LD, TOTAL
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, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for temperature greater than 101.3 F or ANC less than 1000/uL or
Creatinine rise of greater than 0.5 mg/dL above baseline or Creatinine greater than 2 mg/dL or Ejection Fraction less
than LLN.
Treatment Condition A
Verify patient has obtained pretreatment ECG and MUGA or ECHO obtained every 2 to 3 Cycles beginning Cycle 2.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for complaints of visual disturbances due to trametinib and need for ophthalmological evaluation.
Monitoring Parameters (2)
Monitor patient for signs and symptoms of pulmonary toxicity (cough, dyspnea, hypoxia, pleural effusion, or infiltrates)
due to trametinib.
Patient Instructions(1)
Educate patient to take dabrafenib orally at least 1 hour before or 2 hours after a meal. Doses should be administered
approximately 12 hours apart. Do not open, crush, or break capsules. A missed dose may be administered up to 6 hours
prior to the next dose.
Educate patient to take trametinib 1 hour before or 2 hours after a meal. Do not take a missed dose within 12 hours of
the next dose. When taking in combination with dabrafenib, take the once daily trametinib dose at the same time each
day with either the morning or evening dose of dabrafenib.
Patient Instructions(2)
Educate patient regarding risk of diarrhea, rash, and visual disturbances due to trametinib.
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, dabrafenib and trametinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 7 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, AST, ALT, Alkaline Phosphatase,
Total Bilirubin, LDH. PROCEDURE (every other Cycle): ECG and ECHO or MUGA
Cycle 4 –  11/30/2017 through 12/27/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Metastatic NSCLC (Advanced, BRAF V600E mutation); THERAPY: dabrafenib 150 mg by mouth twice daily
continuously, trametinib 2 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Trametinib is expected to cause fetal harm if administered to a pregnant woman. Women of childbearing potential
should use a highly effective contraceptive during therapy and for 4 months after treatment is complete.
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
GLUCOSE
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
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
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
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 8 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Routine
LD, TOTAL
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, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for temperature greater than 101.3 F or ANC less than 1000/uL or
Creatinine rise of greater than 0.5 mg/dL above baseline or Creatinine greater than 2 mg/dL or Ejection Fraction less
than LLN.
Treatment Condition A
Verify patient has obtained pretreatment ECG and MUGA or ECHO obtained every 2 to 3 Cycles beginning Cycle 2.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for complaints of visual disturbances due to trametinib and need for ophthalmological evaluation.
Monitoring Parameters (2)
Monitor patient for signs and symptoms of pulmonary toxicity (cough, dyspnea, hypoxia, pleural effusion, or infiltrates)
due to trametinib.
Patient Instructions(1)
Educate patient to take dabrafenib orally at least 1 hour before or 2 hours after a meal. Doses should be administered
approximately 12 hours apart. Do not open, crush, or break capsules. A missed dose may be administered up to 6 hours
prior to the next dose.
Educate patient to take trametinib 1 hour before or 2 hours after a meal. Do not take a missed dose within 12 hours of
the next dose. When taking in combination with dabrafenib, take the once daily trametinib dose at the same time each
day with either the morning or evening dose of dabrafenib.
Patient Instructions(2)
Educate patient regarding risk of diarrhea, rash, and visual disturbances due to trametinib.
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
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 9 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Oral Chemotherapy Order Management
For this regimen, dabrafenib and trametinib will be ordered through the medication activity after the
initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH. PROCEDURE
(every other Cycle): ECG and ECHO or MUGA
Cycle 5 –  12/28/2017 through 1/24/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Metastatic NSCLC (Advanced, BRAF V600E mutation); THERAPY: dabrafenib 150 mg by mouth twice daily
continuously, trametinib 2 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Trametinib is expected to cause fetal harm if administered to a pregnant woman. Women of childbearing potential
should use a highly effective contraceptive during therapy and for 4 months after treatment is complete.
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
GLUCOSE
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
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 10 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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
LD, TOTAL
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, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for temperature greater than 101.3 F or ANC less than 1000/uL or
Creatinine rise of greater than 0.5 mg/dL above baseline or Creatinine greater than 2 mg/dL or Ejection Fraction less
than LLN.
Treatment Condition A
Verify patient has obtained pretreatment ECG and MUGA or ECHO obtained every 2 to 3 Cycles beginning Cycle 2.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for complaints of visual disturbances due to trametinib and need for ophthalmological evaluation.
Monitoring Parameters (2)
Monitor patient for signs and symptoms of pulmonary toxicity (cough, dyspnea, hypoxia, pleural effusion, or infiltrates)
due to trametinib.
Patient Instructions(1)
Educate patient to take dabrafenib orally at least 1 hour before or 2 hours after a meal. Doses should be administered
approximately 12 hours apart. Do not open, crush, or break capsules. A missed dose may be administered up to 6 hours
prior to the next dose.
Educate patient to take trametinib 1 hour before or 2 hours after a meal. Do not take a missed dose within 12 hours of
the next dose. When taking in combination with dabrafenib, take the once daily trametinib dose at the same time each
day with either the morning or evening dose of dabrafenib.
Patient Instructions(2)
Educate patient regarding risk of diarrhea, rash, and visual disturbances due to trametinib.
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,Edward E [2435061]
9/7/2017 10:59:35 AM Page 11 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, dabrafenib and trametinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH. PROCEDURE
(every other Cycle): ECG and ECHO or MUGA
Cycle 6 –  1/25/2018 through 2/21/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 1/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Metastatic NSCLC (Advanced, BRAF V600E mutation); THERAPY: dabrafenib 150 mg by mouth twice daily
continuously, trametinib 2 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Trametinib is expected to cause fetal harm if administered to a pregnant woman. Women of childbearing potential
should use a highly effective contraceptive during therapy and for 4 months after treatment is complete.
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
GLUCOSE
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
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 12 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
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
LD, TOTAL
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, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for temperature greater than 101.3 F or ANC less than 1000/uL or
Creatinine rise of greater than 0.5 mg/dL above baseline or Creatinine greater than 2 mg/dL or Ejection Fraction less
than LLN.
Treatment Condition A
Verify patient has obtained pretreatment ECG and MUGA or ECHO obtained every 2 to 3 Cycles beginning Cycle 2.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for complaints of visual disturbances due to trametinib and need for ophthalmological evaluation.
Monitoring Parameters (2)
Monitor patient for signs and symptoms of pulmonary toxicity (cough, dyspnea, hypoxia, pleural effusion, or infiltrates)
due to trametinib.
Patient Instructions(1)
Educate patient to take dabrafenib orally at least 1 hour before or 2 hours after a meal. Doses should be administered
approximately 12 hours apart. Do not open, crush, or break capsules. A missed dose may be administered up to 6 hours
prior to the next dose.
Educate patient to take trametinib 1 hour before or 2 hours after a meal. Do not take a missed dose within 12 hours of
the next dose. When taking in combination with dabrafenib, take the once daily trametinib dose at the same time each
day with either the morning or evening dose of dabrafenib.
Patient Instructions(2)
Educate patient regarding risk of diarrhea, rash, and visual disturbances due to trametinib.
Flush Venous Access Device per Guidelines
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 13 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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, dabrafenib and trametinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH. PROCEDURE
(every other Cycle): ECG and ECHO or MUGA
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Zztestonc,Edward E [2435061]
9/7/2017 10:59:35 AM Page 14 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org