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HEM Carfilzomib (28D1,2,8,9,15,16) Dexamethasone (28D1,8,15,22) Lenalidomide (28D1-21) (5249 VER: 10-23-15)

HEM Carfilzomib (28D1,2,8,9,15,16) Dexamethasone (28D1,8,15,22) Lenalidomide (28D1-21) (5249 VER: 10-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-27-16 (5249 VER: 10-23-15) Page 1 of 6
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carfilzomib/Dexamethasone/Lenalidomide
Disease Group: Hematology
Disease: Multiple Myeloma (Relapsed/Refractory)

Therapy:
Cycle 1: carfilzomib 20 mg/m2 IV Day 1 and 2
carfilzomib 27 mg/m2 IV Day 8, 9, 15 and 16
dexamethasone 40 mg by mouth Day 1, 8, 15 and 22
lenalidomide 5 to 25 mg by mouth once daily Day 1 through 21

Cycle ≥ 2: carfilzomib 27 mg/m2 IV Days 1, 2, 8, 9, 15 and 16
dexamethasone 40 mg by mouth Days 1, 8, 15 and 22
lenalidomide 5 to 25 mg by mouth once daily Days 1 through 21

Cycle Length: 28 days Course: until disease progression

NOTE: maximum BSA = 2.2m2 (per physician discretion); thrombosis prophylaxis recommended

Reference(s): Niesvizky R, et al. Clin Cancer Res 2013;19(18):2248-56; Jakubowiak AJ, et al. Blood 2012;120(9):
1801-9, Stewart AK, et al. N Engl J Med 2015;372(2):142-52.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 2 (date) ___________
 Day 8 (date) ___________  Day 9 (date) ___________
 Day 15 (date) __________  Day 16 (date) __________

Pre labs:
• Day 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT,
• Day 8 and 15: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium
• Obtain Urine Pregnancy Test for females of childbearing potential as follows:
 Cycle 1: Obtain Urine Pregnancy Test WEEKLY (Day 1, 8, 15, 22)
 Cycle ≥ 2 with IRREGULAR periods: Obtain Urine Pregnancy test every TWO weeks on Day 1 and 15.
 Cycle ≥ 2 with REGULAR periods: Obtain Urine Pregnancy Test every FOUR weeks on Day 1.
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1, 8, and 15: Hold and notify authorizing provider for ANC < 1000/µL or Platelets < 50K/µL.

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

Hydration/Fluids: sodium chloride 0.9% IV administer 250 to 500 mL prior to treatment.

VER: 09-27-16 (5249 VER: 10-23-15) Page 2 of 6
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
Day 1, 8 and 15:
• *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
• Other:


Day 2, 9 and 16:
• *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
• *dexamethasone (Decadron) 4 mg by mouth once. PO preferred – may give 4 mg IV if unable to tolerate PO.
• Other:


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:




• dexamethasone (Decadron) 40 mg by mouth once.


 Cycle 1
carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should be
flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Monitor patient for hypotension and shortness of breath.

 Cycle ≥ 2
carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should be
flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Monitor patient for hypotension and shortness of breath.


• Refer to Take Home Medications section for lenalidomide










Treatment Medications (continued on next page)

VER: 09-27-16 (5249 VER: 10-23-15) Page 3 of 6
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 2: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• Carfilzomib (Kyprolis):
 Cycle 1
carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should
be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.
Hypersensitivity to carfilzomib can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Monitor patient for hypotension and shortness of breath.

 Cycle ≥ 2
carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should
be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.
Hypersensitivity to carfilzomib can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Monitor patient for hypotension and shortness of breath.


Treatment Medications for Day 8: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• dexamethasone (Decadron) 40 mg by mouth once.

• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should be
flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Monitor patient for hypotension and shortness of breath.

Treatment Medications for Day 9: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should be
flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Monitor patient for hypotension and shortness of breath.



Treatment Medications (continued on next page)

VER: 09-27-16 (5249 VER: 10-23-15) Page 4 of 6
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 15: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• dexamethasone (Decadron) 40 mg by mouth once.

• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should be
flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Monitor patient for hypotension and shortness of breath.

Treatment Medications for Day 16: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line should be
flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Monitor patient for hypotension and shortness of breath.

Conditional Orders for Day 1, 2, 8, 9, 15 and 16:
• sodium chloride 0.9% IV administer 250 to 500 mL if patient becomes hypotensive.



Other Orders for Day 1, 2, 8, 9, 15 and/or 16:








VER: 09-27-16 (5249 VER: 10-23-15) Page 5 of 6
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.

• dexamethasone (Decadron) 4 mg tablet, Disp. #10, Refills: 5
Take 10 tablets (40 mg) by mouth on Day 22.

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth 2 times daily.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

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

• 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:




VER: 09-27-16 (5249 VER: 10-23-15) Page 6 of 6
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1, 2, 8, 9, 15, and 16 every 28 days

• Labs: None
 Other:




• Procedures/Imaging/Scans:



















• Other Orders:













MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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