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GU Atezolizumab (21D1) (5540 VER: 12-1-16)

GU Atezolizumab (21D1) (5540 VER: 12-1-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 12-15-16 (5540 VER: 12-1-16) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Atezolizumab
Disease Group: Genitourinary
Disease: Urothelial Carcinoma (Advanced)

Therapy: atezolizumab 1200 mg IV Day 1

Cycle Length: 21 days Course: until disease progression

Reference(s): Rosenberg JE, et al. Lancet 2016;387 (10031):1909-20

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1, Day 1: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin,
Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase, TSH, T4 (free), Urine
Pregnancy Test (for women of childbearing potential)
 Other:


• Cycle ≥2, Day 1: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin,
Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase. Prior to EVEN cycles only -
obtain additional TSH, T4 (free).
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase
• Hold and notify provider for: AST > 3 X ULN (or > 5 X ULN if known liver metastases) or ALT > 3 X ULN (or >
5 X ULN if known liver metastases) or Total Bilirubin > 1.5 X ULN or Amylase > 2 X ULN or Lipase > 2 X ULN.

Nursing Procedure, Assessment and Monitoring:
• Advise patient to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or
shortness of breath) or colitis (abdominal pain, mucus or blood in stool)
• 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) - None



VER: 12-15-16 (5540 VER: 12-1-16) 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:


• atezolizumab (Tecentriq) 1200 mg IV once over 60 minutes.
If the first infusion is tolerated, all subsequent infusions can be given over 30 minutes. Do not administer
IV push or IV bolus. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated
in a location to optimize emergency care.

Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment) - None


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 #: ________