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CSC Melanoma Ipilimumab (21D:1) Ver 10-25-17 (HL 4243)

CSC Melanoma Ipilimumab (21D:1) Ver 10-25-17 (HL 4243) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA IPILIMUMAB (21D:1) VER: 10-25-17 (HL 4243) –  Properties
Pre-Cycle –  10/25/2017 through 10/31/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 10/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
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
PHOSPHATE
Expected: S Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, DIRECT
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
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 1 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AMYLASE
Expected: S Approximate, Expires: S+365, Routine
LIPASE
Expected: S Approximate, Expires: S+365, Routine
URIC ACID
Expected: S Approximate, Expires: S+365, Routine
TSH
Expected: S Approximate, Expires: S+365, Routine
T4, TOTAL
Expected: S Approximate, Expires: S+365, Routine
T4, FREE
Expected: S Approximate, Expires: S+365, Routine
CORTISOL
Expected: S Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected: S Approximate, Expires: S+365, Routine
Cycle 1 –  11/1/2017 through 11/21/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 11/1/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Hodi FS et al, N Engl J Med 2010;363:711-23
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
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
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 2 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total
Bilirubin greater than 1.5 X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links
in navigator.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
ipilimumab (YERVOY) 240 mg in sodium chloride 0.9 % 120 mL bag
240 mg (3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Provide patient with Medication Guide upon each
administration.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Return to Clinic for appointment with provider; LABS: CBC with DIFF, Sodium, Potassium, Chloride,
Carbon Dioxide, BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT,
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 3 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Alkaline Phosphatase, LDH, Uric acid, Lipase, Amylase, TSH, T4, Free T4, and Cortisol; CHEMOTHERAPY ROOM
APPOINTMENT: ipilumumab for 60 minutes
Cycle 2 –  11/22/2017 through 12/12/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 11/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
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+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
Expected: S+21, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, DIRECT
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 4 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+21, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
URIC ACID
Expected: S+21, Expires: S+365, Routine
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
T4, TOTAL
Expected: S Approximate, Expires: S+365, Routine
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
CORTISOL
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total
Bilirubin greater than 1.5 X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links
in navigator.
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.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 5 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
ipilimumab (YERVOY) 240 mg in sodium chloride 0.9 % 120 mL bag
240 mg (3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Provide patient with Medication Guide upon each
administration.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Return to Clinic for appointment with provider; LABS: CBC with DIFF, Sodium, Potassium, Chloride,
Carbon Dioxide, BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT,
Alkaline Phosphatase, LDH, Uric acid, Lipase, Amylase, TSH, T4, Free T4, and Cortisol; CHEMOTHERAPY ROOM
APPOINTMENT: ipilumumab for 60 minutes
Cycle 3 –  12/13/2017 through 1/2/2018 (21 days), Planned
Cycle 4 –  1/3/2018 through 1/23/2018 (21 days), Planned
Day 1, Cycle 4 –  Planned for 1/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 6 of 9
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 WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
PROTEIN, TOTAL
Expected: S+21, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, DIRECT
Expected: S+21, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
URIC ACID
Expected: S+21, Expires: S+365, Routine
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 7 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

T4, TOTAL
Expected: S Approximate, Expires: S+365, Routine
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
CORTISOL
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total
Bilirubin greater than 1.5 X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links
in navigator.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
ipilimumab (YERVOY) 240 mg in sodium chloride 0.9 % 120 mL bag
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Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 8 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

240 mg (3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Provide patient with Medication Guide upon each
administration.
Follow-Up
DAY 29 FOLLOW-UP
Return to Clinic for appointment with provider; LABS: CBC with DIFF, Sodium, Potassium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline
Phosphatase, LDH, Uric Acid, Lipase, Amylase, TSH , T4, Free T4, and Cortisol.
Actions
Actions
Zztestonc,Jeff J [2507481]
11/1/2017 10:27:51 AM Page 9 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org