/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/ppo/,

/clinical/cckm-tools/content/ppo/name-101219-en.cckm

201608217

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Preprinted Paper Orders

Melanoma Pembrolizumab 21D1 (5196 VER: 11-2-15)

Melanoma Pembrolizumab 21D1 (5196 VER: 11-2-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 06-21-16 (5196 VER: 11-2-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Pembrolizumab
Disease Group: Melanoma
Disease: Melanoma (Advanced/Metastatic)

Therapy: pembrolizumab 2 mg/kg IV Day 1

Cycle Length: 21 days Course: until disease progression

Reference(s): Robert C, et al. Lancet 2014 Sep 20;20;384(9948):1109-17. doi: 10.1016/S0140-6736(14)60958-
2. Epub 2014 Jul 15

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________

Pre labs:
• Day 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total
Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Lipase, Amylase
 Other:


• Cycle 1, Day 1 - Obtain additional labs: Serum Pregnancy Test (for women of childbearing potential), TSH, T4
(free)

• All Even Cycles – Obtain additional labs: TSH, T4 (free)


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.

Nursing Procedure, Assessment and Monitoring:
• Notify provider for systolic blood pressure < 100 mmHg (if below pre-infusion blood pressure) or for any
symptoms of hypotension.
• Monitor blood pressure, heart rate, temperature, respiratory rate and pain level every 15 minutes during
pembrolizumab infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level
30 minutes after first pembrolizumab dose.
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:




Final Approved VER: 06-21-16 (5196 VER: 11-2-15) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• pembrolizumab (Keytruda) __________mg (2 mg/kg) IV once over 30 minutes through an intravenous line
containing a sterile, non-pyrogenic, low-protein binding 0.22 micron in-line filter. Do not co-administer other
drugs through same infusion line. Hypersensitivity risk. For first and second dose, patient should be treated in
a location to optimize emergency care. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.

Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

 Other:



Follow Up
• Chemotherapy: Day 1 every 21 days

• Labs:
 Other:


• Procedures/Imaging/Scans:





• Other Orders:





MD Signature_________________________________________ Pager______________
Date __________________Time___________________

Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________