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/clinical/cckm-tools/content/beacon-protocols/supportive-care/name-122936-en.cckm

201711331

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Supportive Care

CSC SC Eculizumab (Soliris) 600 mg Every Wk X4 Loading and 900 mg Every 2Wk Maintenance Ver 11-20-17 (HL 1911)

CSC SC Eculizumab (Soliris) 600 mg Every Wk X4 Loading and 900 mg Every 2Wk Maintenance Ver 11-20-17 (HL 1911) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Supportive Care


CSC SC ECULIZUMAB (SOLIRIS) 600 MG EVERY WK X4 LOADING AND 900 MG EVERY 2WK MAINTENANCE
VER: 11-20-17 –  Properties
Cycle 1 - Loading Dose Cycle –  11/21/2017 through 12/18/2017 (28 days), Planned
Day 1, Cycle 1 - Loading Dose Cycle –  Planned for 11/21/2017
Treatment Conditions
Treatment Condition A
Verify patient has received Meningococcal vaccine at least 2 weeks prior to first dose of eculizumab.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 600 mg in sodium chloride 0.9 % 120 mL bag
600 mg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See Emergency Medications.
Day 8, Cycle 1 - Loading Dose Cycle –  Planned for 11/28/2017
Treatment Conditions
Treatment Condition A
Verify patient has received Meningococcal vaccine at least 2 weeks prior to first dose of eculizumab.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 1 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 600 mg in sodium chloride 0.9 % 120 mL bag
600 mg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See Emergency Medications.
Day 15, Cycle 1 - Loading Dose Cycle –  Planned for 12/5/2017
Treatment Conditions
Treatment Condition A
Verify patient has received Meningococcal vaccine at least 2 weeks prior to first dose of eculizumab.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 2 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Supportive Care Medications
eculizumab (SOLIRIS) 600 mg in sodium chloride 0.9 % 120 mL bag
600 mg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See Emergency Medications.
Day 22, Cycle 1 - Loading Dose Cycle –  Planned for 12/12/2017
Treatment Conditions
Treatment Condition A
Verify patient has received Meningococcal vaccine at least 2 weeks prior to first dose of eculizumab.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 600 mg in sodium chloride 0.9 % 120 mL bag
600 mg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See Emergency Medications.
Cycle 2 –  12/19/2017 through 1/15/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 12/19/2017
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Actions
Actions
Actions
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 3 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Day 15, Cycle 2 –  Planned for 1/2/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 4 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Cycle 3 –  1/16/2018 through 2/12/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 1/16/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Day 15, Cycle 3 –  Planned for 1/30/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 5 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Cycle 4 –  2/13/2018 through 3/12/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 2/13/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Day 15, Cycle 4 –  Planned for 2/27/2018
Nursing Procedure, Assessment and Monitoring
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 6 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Cycle 5 –  3/13/2018 through 4/9/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 3/13/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 7 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

famotidine (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Day 15, Cycle 5 –  Planned for 3/27/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Cycle 6 –  4/10/2018 through 5/7/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/10/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Actions
Actions
Actions
Actions
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 8 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
900 mg, Intravenous, ONCE, 1 dose Starting when released
Day 15, Cycle 6 –  Planned for 4/24/2018
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to eculizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Please provide patient with Eculizumab Medication Guide each time patient receives eculizumab. Go to reference links
in navigator.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 (PEPCID) 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
Supportive Care Medications
eculizumab (SOLIRIS) 900 mg in sodium chloride 0.9 % 180 mL bag
Actions
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Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 9 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

900 mg, Intravenous, ONCE, 1 dose Starting when released
Zztestonc,Fiona F [2462287]
11/21/2017 10:17:00 AM Page 10 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org