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Lung Atezolizumab (21D1) (6106 VER: 12-29-16)

Lung Atezolizumab (21D1) (6106 VER: 12-29-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 3-8-16 (6106 VER: 12-29-16) Page 1 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Atezolizumab
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Advanced)

Therapy: atezolizumab 1200 mg IV Day 1

Cycle Length: 21 days Course: until disease progression

Reference(s): Fehrenbacher L, et al. Lancet 2016;387(10030):1837-46; Barlesi F, et al. Ann Oncol
2016;27(suppl 6):abstract LBA 44.

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, free T4, 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. Obtain TSH, free T4 prior to
even cycles only.
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase
• Hold and notify provider for: AST > 3 x ULN (> 5 x ULN if known liver metastases) or ALT > 3 x ULN (> 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 patients 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: 3-8-16 (6106 VER: 12-29-16) Page 2 of 2
Copyright © 2017 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 risk. 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 #: ________