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201611333

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Lung

CSC Lung Crizotinib(28D:1-18) VER 3-5-15 (HL 4425)

CSC Lung Crizotinib(28D:1-18) VER 3-5-15 (HL 4425) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CRIZOTINIB(28D:1-28) VER: 10-3-16 – Properties
Pre-Cycle – 11/21/2016 through 11/27/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced) (ALK- positive); THERAPY: crizotinib 250 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Crizotinib prolongs the QT interval and should be used with caution in patients with hypokalemia, hypomagnesemia, or long QT
syndrome as sudden death has been reported in these 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
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
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
Cycle 1 – 11/28/2016 through 12/25/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
NON SMALL CELL LUNG CANCER: Riely GJ, et al. Profile 1005. World Conference on Lung Cancer July 2011. Abstract 1618.
Reference Information (2)
NON SMALL CELL LUNG CANCER: Kwak EL, et al. N Engl J Med 2010;363:1693-703
Reference Information (3)
NON SMALL CELL LUNG CANCER: Camidge DR, et al. J Clin Oncol 29:2011 (suppl; abstr 2501)
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced) (ALK- positive); THERAPY: crizotinib 250 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:33:13 PM Page 1 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note to All Staff (1)
Crizotinib prolongs the QT interval and should be used with caution in patients with hypokalemia, hypomagnesemia,
or long QT syndrome as sudden death has been reported in these 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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, or AST
greater than or equal to ULN, ALT greater than or equal to ULN, Alkaline Phosphatase greater than or equal to ULN, or Total
Bilirubin greater than or equal to ULN.
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 medications section for the following treatment medication(s): crizotinib (dispensed Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications (delete all that do not apply)
crizotinib (XALKORI) 250 MG cap
Take 1 cap by mouth 2 times daily., 250 mg, Disp-60 cap, R-0, 2 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, ANC (DIFF if done locally), Electrolytes, BUN,
Creatinine, AST, ALT, Alkaline Phosphatase and Total Bilirubin.
Cycle 2 – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced) (ALK- positive); THERAPY: crizotinib 250 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/28/2016 2:33:13 PM Page 2 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Crizotinib prolongs the QT interval and should be used with caution in patients with hypokalemia, hypomagnesemia, or long QT
syndrome as sudden death has been reported in these 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
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
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, or AST
greater than or equal to ULN, ALT greater than or equal to ULN, Alkaline Phosphatase greater than or equal to ULN, or Total
Bilirubin greater than or equal to ULN.
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
Oral Chemotherapy Order Management
For this regimen, crizotinib will be ordered through the medication activity after the initial order.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 2:33:13 PM Page 3 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally),
Electrolytes, BUN, Creatinine, AST, ALT, Alkaline Phosphatase and Total Bilirubin.
Cycle 3 – 1/23/2017 through 2/19/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced) (ALK- positive); THERAPY: crizotinib 250 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Crizotinib prolongs the QT interval and should be used with caution in patients with hypokalemia, hypomagnesemia, or long QT
syndrome as sudden death has been reported in these 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
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
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, or AST
greater than or equal to ULN, ALT greater than or equal to ULN, Alkaline Phosphatase greater than or equal to ULN, or Total
Bilirubin greater than or equal to ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/28/2016 2:33:13 PM Page 4 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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, crizotinib 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, ANC (DIFF if done locally), Electrolytes, BUN,
Creatinine, AST, ALT, Alkaline Phosphatase and Total Bilirubin.
Cycle 4 – 2/20/2017 through 3/19/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced) (ALK- positive); THERAPY: crizotinib 250 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Crizotinib prolongs the QT interval and should be used with caution in patients with hypokalemia, hypomagnesemia, or long QT
syndrome as sudden death has been reported in these 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
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
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
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,Andrew [2428787]
11/28/2016 2:33:13 PM Page 5 of 8
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: ANC, Platelets, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, or AST
greater than or equal to ULN, ALT greater than or equal to ULN, Alkaline Phosphatase greater than or equal to ULN, or Total
Bilirubin greater than or equal to ULN.
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
Oral Chemotherapy Order Management
For this regimen, crizotinib 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, ANC (DIFF if done locally), Electrolytes, BUN,
Creatinine, AST, ALT, Alkaline Phosphatase and Total Bilirubin.
Cycle 5 – 3/20/2017 through 4/16/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced) (ALK- positive); THERAPY: crizotinib 250 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Crizotinib prolongs the QT interval and should be used with caution in patients with hypokalemia, hypomagnesemia, or long QT
syndrome as sudden death has been reported in these 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
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
BUN
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ZZtestonc,Andrew [2428787]
11/28/2016 2:33:13 PM Page 6 of 8
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
CREATININE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, or AST
greater than or equal to ULN, ALT greater than or equal to ULN, Alkaline Phosphatase greater than or equal to ULN, or Total
Bilirubin greater than or equal to ULN.
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
Oral Chemotherapy Order Management
For this regimen, crizotinib 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, ANC (DIFF if done locally), Electrolytes, BUN,
Creatinine, AST, ALT, Alkaline Phosphatase and Total Bilirubin.
Cycle 6 – 4/17/2017 through 5/14/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced) (ALK- positive); THERAPY: crizotinib 250 mg by mouth twice daily continuously;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Crizotinib prolongs the QT interval and should be used with caution in patients with hypokalemia, hypomagnesemia, or long QT
syndrome as sudden death has been reported in these patients.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 2:33:13 PM Page 7 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, or AST
greater than or equal to ULN, ALT greater than or equal to ULN, Alkaline Phosphatase greater than or equal to ULN, or Total
Bilirubin greater than or equal to ULN.
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
Oral Chemotherapy Order Management
For this regimen, crizotinib 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, ANC (DIFF if done locally), Electrolytes, BUN,
Creatinine, AST, ALT, Alkaline Phosphatase and Total Bilirubin.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:33:13 PM Page 8 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org