/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/sarcoma/,

/clinical/cckm-tools/content/beacon-protocols/sarcoma/name-117488-en.cckm

201706165

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100

UWHC,UWMF,

Tools,

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

CSC Sarcoma Temolomide(42D1-28) VER 5-1-17 (HL 2433)

CSC Sarcoma Temolomide(42D1-28) VER 5-1-17 (HL 2433) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA TEMOZOLOMIDE(42D1-28) VER 5-1-17 (HL 2433) – Properties
Pre-Cycle – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth every Mon,Wed,Fri., 1 tab, Disp-18 tab, R-5, EVERY MON, WED, FRI starting S
Contact MD for alternate if Sulfa allergy. For pneumocystis carinii prophylaxis.
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab orally before temozolomide and every 8h as needed for nausea, Disp-84 tab, R-5, starting S
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 – 6/13/2017 through 7/24/2017 (42 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Garcia del Muro X, et al. Cancer 2005;104(8):1706-12.
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 1 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 180 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 100 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 20 MG cap
Take 7 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 5 MG cap
Take 29 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 145 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
75 mg/m2 (147 mg = 0.588 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (128 mg/m2).
75 mg/m2 (147 mg = 0.8167 cap) cannot be prescribed using the selected product.
The nearest available dose is 180 mg (91.8 mg/m2).
75 mg/m2 (147 mg = 1.47 cap) cannot be prescribed using the selected product.
The nearest available dose is 100 mg (51 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 2 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 43 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, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: none.
Day 22 Lab only, Cycle 1 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 Lab only, Cycle 1 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/25/2017 through 9/4/2017 (42 days), Planned
Day 1, Cycle 2 – Planned for 7/25/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 3 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through
28; CYCLE LENGTH: 42 days; COURSE: until disease progression.
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+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+42 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+42 Approximate, Expires-S+365, Routine
BUN
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
75 mg/m2 (147 mg = 0.588 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (128 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 4 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 180 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 100 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 20 MG cap
Take 7 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 5 MG cap
Take 29 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 145 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 43 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, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: none.
Day 22 Lab only, Cycle 2 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 Lab only, Cycle 2 – Planned for 8/22/2017
75 mg/m2 (147 mg = 0.8167 cap) cannot be prescribed using the selected product.
The nearest available dose is 180 mg (91.8 mg/m2).
75 mg/m2 (147 mg = 1.47 cap) cannot be prescribed using the selected product.
The nearest available dose is 100 mg (51 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 5 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 9/5/2017 through 10/16/2017 (42 days), Planned
Day 1, Cycle 3 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+42 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+42 Approximate, Expires-S+365, Routine
BUN
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 6 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 180 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 100 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 20 MG cap
Take 7 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 5 MG cap
Take 29 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 145 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 43 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, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: none.
75 mg/m2 (147 mg = 0.588 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (128 mg/m2).
75 mg/m2 (147 mg = 0.8167 cap) cannot be prescribed using the selected product.
The nearest available dose is 180 mg (91.8 mg/m2).
75 mg/m2 (147 mg = 1.47 cap) cannot be prescribed using the selected product.
The nearest available dose is 100 mg (51 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 7 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 22 Lab only, Cycle 3 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 Lab only, Cycle 3 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 10/17/2017 through 11/27/2017 (42 days), Planned
Day 1, Cycle 4 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 8 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+42 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+42 Approximate, Expires-S+365, Routine
BUN
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 180 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
75 mg/m2 (147 mg = 0.588 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (128 mg/m2).
75 mg/m2 (147 mg = 0.8167 cap) cannot be prescribed using the selected product.
The nearest available dose is 180 mg (91.8 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 9 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

temozolomide (TEMODAR) 100 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 100 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 20 MG cap
Take 7 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 5 MG cap
Take 29 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 145 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 43 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, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: none.
Day 22 Lab only, Cycle 4 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 Lab only, Cycle 4 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
75 mg/m2 (147 mg = 1.47 cap) cannot be prescribed using the selected product.
The nearest available dose is 100 mg (51 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 10 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 11/28/2017 through 1/8/2018 (42 days), Planned
Day 1, Cycle 5 – Planned for 11/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+42 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+42 Approximate, Expires-S+365, Routine
BUN
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 11 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 180 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 100 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 20 MG cap
Take 7 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 5 MG cap
Take 29 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 145 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 43 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, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: none.
Day 22 Lab only, Cycle 5 – Planned for 12/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
IV Access
75 mg/m2 (147 mg = 0.588 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (128 mg/m2).
75 mg/m2 (147 mg = 0.8167 cap) cannot be prescribed using the selected product.
The nearest available dose is 180 mg (91.8 mg/m2).
75 mg/m2 (147 mg = 1.47 cap) cannot be prescribed using the selected product.
The nearest available dose is 100 mg (51 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 12 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 Lab only, Cycle 5 – Planned for 12/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 1/9/2018 through 2/19/2018 (42 days), Planned
Day 1, Cycle 6 – Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 13 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+42 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+42 Approximate, Expires-S+365, Routine
BUN
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 180 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 140 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 100 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 20 MG cap
75 mg/m2 (147 mg = 0.588 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (128 mg/m2).
75 mg/m2 (147 mg = 0.8167 cap) cannot be prescribed using the selected product.
The nearest available dose is 180 mg (91.8 mg/m2).
75 mg/m2 (147 mg = 1.47 cap) cannot be prescribed using the selected product.
The nearest available dose is 100 mg (51 mg/m2).
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 14 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take 7 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose =
*** mg, 140 mg (rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S
Round dose to available capsule sizes.
temozolomide (TEMODAR) 5 MG cap
Take 29 caps by mouth one time daily. Take Day 1 thru 28. Swallow whole on empty stomach. Total daily dose = *** mg, 145 mg
(rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to available capsule sizes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 43 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, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: none.
Day 22 Lab only, Cycle 6 – Planned for 1/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 Lab only, Cycle 6 – Planned for 2/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Leiomyosarcoma (Advanced); THERAPY: temozolomide 75 mg/m2/day by mouth daily Day 1 through 28; CYCLE
LENGTH: 42 days; COURSE: until disease progression.
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
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 15 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:03:22 PM Page 16 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org