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Hem Lenalidomide (28D1-21) (5020 Ver 2-2-16)

Hem Lenalidomide (28D1-21) (5020 Ver 2-2-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-13-16 (5020 VER: 02-02-16) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Lenalidomide
Disease Group: Hematology
Disease: Mantle Cell Lymphoma (Relapsed or Progressive Disease)

Therapy: Lenalidomide 25 mg by mouth once daily Day 1 through 21

Cycle Length: 28 days Course: until disease progression

NOTE: thrombosis prophylaxis recommended

Reference(s): Goy A, et al. J Clin Oncol 2013;31(29):3688-95.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC with DIFF, LDH, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total
Bilirubin, AST, ALT, Alkaline Phosphatase, Urine Pregnancy Test (for women of childbearing potential)
• CYCLE 1 ONLY: Obtain Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15,
22)
• CYCLE ≥ 2 with IRREGULAR periods: Obtain Urine Pregnancy test every TWO weeks for females of
childbearing potential with irregular periods on Day 1 and 15.
• CYCLE ≥ 2 with REGULAR periods: Obtain Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 1.
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC with DIFF, Creatinine
• Hold and notify authorizing provider for: ANC < 1000/µL or Platelets < 50K/µL or Creatinine Clearance < 60
mL/min.
• Consider holding treatment for ANC < 1000/µL for ≥ 7 days or ANC less than 1000/µL with associated fever ≥
38.5°C or ANC < 500/µL at any time. Resume lenalidomide at 5 mg less than previous dose once ANC ≥
1000/µL and Platelets ≥ 50K/µL

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

Hydration/Fluids: None

Premedications/Antiemetics: None

Treatment Medications: Refer to Take Home Medications section

Other Orders:



VER: 09-13-16 (5020 VER: 02-02-16) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
lenalidomide (Revlimid) _________ mg (available as 5 mg, 10 mg, 15 mg, 25 mg capsules)
Disp. # __________, Refills: 0; Verify compliance with Revlimid REMS Program.

Take ___________ mg by mouth once daily on Day 1 through 21.

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth two times daily.

• Thrombosis Prophylaxis:
 aspirin 325 mg EC tablet, Disp. Available OTC
Take 1 tablet (325 mg) by mouth one time daily.

 enoxaparin (Lovenox) 40 mg/0.4 mL injection, Disp. #30, Refills: 11
Inject 40 mg under skin one time daily.

 warfarin (Coumadin) 5 mg tablet, Disp. #30, Refills: 11
Take 1 tablet (5 mg) by mouth one time daily.

 Other:






Follow Up
• Chemotherapy: Day 1 through 21 every 28 days

• Interim Labs needed:

Cycle 1: CBC with DIFF, Urine Pregnancy Test (for women of childbearing potential)
 Day 8 _____________ (Date)
 Day 15 ____________ (Date)
 Day 22 _____________(Date)

Cycle 2, 3, and 4: CBC with DIFF (all patients) and Urine Pregnancy Test (for women of childbearing
potential with IRREGULAR periods)
 Day 15 ____________ (Date)

 Other:




Follow Up Orders continued on next page:

VER: 09-13-16 (5020 VER: 02-02-16) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Follow up (cont.)
• Procedures/Imaging/Scans:



















• Other Orders:

















MD Signature_____________________________ Pager______________
Date _____________Time______________

Order verification:
RN Signature: _________________ Date: _______ Time: ______ Pager #: ________
RPh Signature: ________________ Date: _______ Time: ______ Pager #: ________