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/clinical/cckm-tools/content/beacon-protocols/lung/name-96964-en.cckm

201711320

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UWHC,UWMF,

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

CSC Lung Ceritinib(28D:1-28) VER 11-15-17 (HL 5343)

CSC Lung Ceritinib(28D:1-28) VER 11-15-17 (HL 5343) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CERITINIB (28D1-28) VER 11-15-17 (HL 5343) –  Properties
Pre-Cycle –  11/8/2017 through 11/14/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-small Cell Lung Cancer (Advanced, ALK positive); THERAPY: ceritinib 750 mg by mouth once daily
continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Alectinib is preferred LUNG DOT agent for frontline advanced, ALK positive NSCLC.
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+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+397, Routine
Take Home Medications
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 1 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max
dose=8 tab/day, Disp-30 cap, R-5, starting S
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
Cycle 1 –  11/15/2017 through 12/12/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 11/15/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shaw AT, et al. N Engl J Med 2014;370:1189-97.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Soria JC, et al. Lancet 2017;389:917-29.
Treatment Plan Summary
DISEASE: Non-small Cell Lung Cancer (Advanced, ALK positive); THERAPY: ceritinib 750 mg by mouth once daily
continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Alectinib is preferred LUNG DOT agent for frontline advanced, ALK positive NSCLC.
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 and resulted:  CBC, ANC, Total Bilirubin, AST and  ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
100K/uL or Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN  (or greater than 5 X ULN if known liver
metastases) or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases).
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,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 2 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient on possibility of hyperglycemia and signs/symptoms of high blood sugar. No grapefruit or grapefruit
juice.
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): ceritinib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Take Home Medications
ceritinib (ZYKADIA) 150 MG cap
Take 5 capsules by mouth once daily on an empty stomach, not within 2 hrs of a meal. No grapefruit or grapefruit
juice., Disp-140 cap, R-0, 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline
Phosphatase.
Cycle 2 –  12/13/2017 through 1/9/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-small Cell Lung Cancer (Advanced, ALK positive); THERAPY: ceritinib 750 mg by mouth once daily
continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Alectinib is preferred LUNG DOT agent for frontline advanced, ALK positive NSCLC.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 3 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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+397, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+397, Routine
BUN
Expected: S+28 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted:  CBC, ANC, Total Bilirubin, AST and  ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
100K/uL or Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN  (or greater than 5 X ULN if known liver
metastases) or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases).
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient on possibility of hyperglycemia and signs/symptoms of high blood sugar. No grapefruit or grapefruit
juice.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 4 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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, ceritinib 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline
Phosphatase.
Cycle 3 –  1/10/2018 through 2/6/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 1/10/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-small Cell Lung Cancer (Advanced, ALK positive); THERAPY: ceritinib 750 mg by mouth once daily
continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Alectinib is preferred LUNG DOT agent for frontline advanced, ALK positive NSCLC.
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
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+397, Routine
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 5 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

BUN
Expected: S+28 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted:  CBC, ANC, Total Bilirubin, AST and  ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
100K/uL or Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN  (or greater than 5 X ULN if known liver
metastases) or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases).
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient on possibility of hyperglycemia and signs/symptoms of high blood sugar. No grapefruit or grapefruit
juice.
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, ceritinib will be ordered through the medication activity after the initial order.
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 6 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@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),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline
Phosphatase.
Cycle 4 –  2/7/2018 through 3/6/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 2/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-small Cell Lung Cancer (Advanced, ALK positive); THERAPY: ceritinib 750 mg by mouth once daily
continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Alectinib is preferred LUNG DOT agent for frontline advanced, ALK positive NSCLC.
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
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+397, Routine
BUN
Expected: S+28 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 7 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+28 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted:  CBC, ANC, Total Bilirubin, AST and  ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
100K/uL or Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN  (or greater than 5 X ULN if known liver
metastases) or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases).
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient on possibility of hyperglycemia and signs/symptoms of high blood sugar. No grapefruit or grapefruit
juice.
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, ceritinib 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline
Phosphatase.
Cycle 5 –  3/7/2018 through 4/3/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 3/7/2018
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 8 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DISEASE: Non-small Cell Lung Cancer (Advanced, ALK positive); THERAPY: ceritinib 750 mg by mouth once daily
continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Alectinib is preferred LUNG DOT agent for frontline advanced, ALK positive NSCLC.
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
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+397, Routine
BUN
Expected: S+28 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted:  CBC, ANC, Total Bilirubin, AST and  ALT.
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 9 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less
than or equal to 100K/uL or Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN  (or
greater than 5 X ULN if known liver metastases) or ALT greater than 2.5 X ULN (or greater than 5 X ULN
if known liver metastases).
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient on possibility of hyperglycemia and signs/symptoms of high blood sugar. No grapefruit or grapefruit
juice.
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, ceritinib 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline
Phosphatase.
Cycle 6 –  4/4/2018 through 5/1/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/4/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-small Cell Lung Cancer (Advanced, ALK positive); THERAPY: ceritinib 750 mg by mouth once daily
continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Alectinib is preferred LUNG DOT agent for frontline advanced, ALK positive NSCLC.
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.
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 10 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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+397, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+397, Routine
BUN
Expected: S+28 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S+28 Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted:  CBC, ANC, Total Bilirubin, AST and  ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL or Platelets less than or equal to
100K/uL or Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN  (or greater than 5 X ULN if known liver
metastases) or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases).
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient on possibility of hyperglycemia and signs/symptoms of high blood sugar. No grapefruit or grapefruit
juice.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 11 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@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, ceritinib 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline
Phosphatase.
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Zztestonc,Jeff J [2507481]
11/15/2017 12:28:13 PM Page 12 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org