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HEM Imatinib (28D 1-28) (1887 VER 11-23-15)

HEM Imatinib (28D 1-28) (1887 VER 11-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-01-16 (1887 VER: 11-23-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Imatinib
Disease Group: Hematology
Disease: Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive), Chronic Myelogenous Leukemia
(Chronic Phase), Chronic Myelogenous Leukemia (Accelerated/Blast Phase), Hypereosinophilic Syndrome (HES)

Therapy for Acute Lymphoblastic Leukemia (Philadelphia Chromosome Positive):
imatinib 600 mg by mouth daily (may increase dose to imatinib 800 mg by mouth daily for disease
progression or lack of response)
Therapy for Chronic Myelogenous Leukemia (Chronic Phase):
imatinib 400 mg by mouth daily
Therapy for Chronic Myelogenous Leukemia (Accelerated/Blast Phase):
imatinib 600 mg by mouth once daily
Therapy for Hypereosinophilic Syndrome (HES):
imatinib 400 mg by mouth daily (For patients with the FIP1L1-PDGFRalpha infusion kinase, the starting dose
is imatinib 100 mg by mouth daily)


Cycle Length: Cycle 1 thorough 3 = 28 days; Cycle 4+ may be extended to 84 days

Course: until disease progression

Reference(s): Ottmann O, et al. Cancer 2007;109(10):2068-76;
O’Brien S, et al. N Engl J Med 2003;348(11):994-1004; Druker B, et al. N Engl J Med 2006;355(23):2408-17;
Baccarani M, et al. Haematologica 2007;92(9):1173-79; Cools J, et al. N Engl J Med 2003;348(13):1201-14.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs: Obtain CBC with DIFF, Creatinine, Total Bilirubin
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin
• Hold and notify provider for: ANC < 1000/µL or Platelets < 75K/µL or Creatinine Clearance < 40 mL/min or
Total Bilirubin > 4 mg/dL

Nursing Procedure, Assessment and Monitoring:
• Flush/Line Care per Institution standards

Hydration/Fluids: None

Premedications/Antiemetics: None

VER: 09-01-16 (1887 VER: 11-23-15) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1: See Take Home Medications section

Other Orders for Day 1:





Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• Imatinib (Gleevec) ________ mg tablet. (Available tablet sizes 400 mg and 100 mg)
Take ________ mg by mouth once daily. No grapefruit products.



 Other:




Follow Up
• Clinic Visit: Day 1 every 28 days for 3 cycles followed by Day 1 every 84 days until disease progression

• Labs:
 Other:


• Procedures/Imaging/Scans:







• Other Orders:







MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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