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Hem Daratumumab(28D) 3 PDF Sections (6105 VER: 09-20-17)

Hem Daratumumab(28D) 3 PDF Sections (6105 VER: 09-20-17) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-21-17 (6105 VER: 09-20-17) Cycle 1 & 2; Page 1 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Daratumumab – Cycle 1 and 2 ONLY
Disease Group: Hematology
Disease: Multiple Myeloma (Advanced)

Therapy:
Cycle 1 to 2: daratumumab 16 mg/kg IV Day 1, 8, 15 and 22

Cycle 3 to 6: daratumumab 16 mg/kg IV Day 1 and 15

Cycle ≥ 7: daratumumab 16 mg/kg IV Day 1

Cycle Length: 28 days Course: until disease progression

Note to all Staff: Chemotherapy Council approved for patients who have received at least three prior therapies,
including a proteasome inhibitor and immunomodulatory agents or who are double refractory to a proteasome
inhibitor and immunomodulatory agent.

Reference(s): Lokhorst HM, et al. N Engl J Med 2015;373(13):1207-19.
de Weers M, et al. J Immunol 2011;186(3):1840-1848.
DARZALEX (Daratumumab) [package insert]. Horsham, PA; Janssen Biotech, Inc; November 2015.
NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. Version 3.2016. Updated Janauary 15, 2016.
Accessed April 18, 2016. http://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 8 (date) ___________
 Day 15 (date) ___________  Day 22 (date) ___________

Pre labs:
• Cycle 1, Day 1: Obtain Type and Screen, RBC Phenotyping, CBC without DIFF, ANC, Glucose, Creatinine,
ALT, Alkaline Phosphatase, Total Bilirubin
 Other:

• Cycle 2, Day 1: Obtain Type and Screen, CBC without DIFF, ANC, Glucose, Creatinine, ALT, Alkaline
Phosphatase, Total Bilirubin
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline
Phosphatase, Total Bilirubin
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 75K/µL or Hemoglobin < 7.5 g/dL or
Creatinine > 2 X ULN or ALT > 3.5 X ULN or Alkaline Phosphatase > 3.5 X ULN or Total Bilirubin > 2.5 X ULN
• Verify that patient has taken home dexamethasone and document.





VER: 09-21-17 (6105 VER: 09-20-17) Cycle 1 & 2; Page 2 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Nursing Procedure, Assessment and Monitoring:
• Monitor vital signs every 30 minutes during daratumumab.
• Instruct patient to pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment. .
• 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)
Give 60 minutes prior to daratumumab:
• acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 25 mg by mouth once
• Cycle 1 - Day 1 and 8: dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not
take dexamethasone at home.
• Cycle 1 - Day 15 and 22 dexamethasone option:
 dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
 dexamethasone (Decadron) 10 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
• Cycle 2 - Day 1, 8, 15 and 22 dexamethasone option:
 dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
 dexamethasone (Decadron) 10 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.

Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:

• daratumumab (Darzalex) __________mg (16 mg/kg) IV once. Allow infusion to come to room temperature
prior to administration. Administer with a 0.22 micrometer filter.
o First infusion (in 1000 mL): initial infusion rate is 50 mL/hr. If no infusion reactions, may increase rate
by 50 mL/hr every hour to a maximum rate to 200 mL/hr.
o Second infusion (in 500 mL): Infuse at 50 mL/hr for the first hour. Escalate the rate only if there were
no grade 1 (mild) or greater infusion reactions during the first 3 hours of the first infusion. If no infusion
reaction occurs, escalate the rate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.
o Subsequent infusions (in 500 mL): Infuse at 100 mL/hr. Escalate only if there were no Grade 1 (mild)
or greater infusion reactions during a final infusion rate of ≥ 100 mL/hr in the first two infusions.
Escalate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.





Treatment Medications (continued on next page)




VER: 09-21-17 (6105 VER: 09-20-17) Cycle 1 & 2; Page 3 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 8:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:

• daratumumab (Darzalex) __________mg (16 mg/kg) IV once. Allow infusion to come to room temperature
prior to administration. Administer with a 0.22 micrometer filter.
o First infusion (in 1000 mL): initial infusion rate is 50 mL/hr. If no infusion reactions, may increase rate
by 50 mL/hr every hour to a maximum rate to 200 mL/hr.
o Second infusion (in 500 mL): Infuse at 50 mL/hr for the first hour. Escalate the rate only if there were
no grade 1 (mild) or greater infusion reactions during the first 3 hours of the first infusion. If no infusion
reaction occurs, escalate the rate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.
o Subsequent infusions (in 500 mL): Infuse at 100 mL/hr. Escalate only if there were no Grade 1 (mild)
or greater infusion reactions during a final infusion rate of ≥ 100 mL/hr in the first two infusions.
Escalate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.


Treatment Medications for Day 15:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• daratumumab (Darzalex) __________mg (16 mg/kg) IV once. Allow infusion to come to room temperature
prior to administration. Administer with a 0.22 micrometer filter.
o First infusion (in 1000 mL): initial infusion rate is 50 mL/hr. If no infusion reactions, may increase rate
by 50 mL/hr every hour to a maximum rate to 200 mL/hr.
o Second infusion (in 500 mL): Infuse at 50 mL/hr for the first hour. Escalate the rate only if there were
no grade 1 (mild) or greater infusion reactions during the first 3 hours of the first infusion. If no infusion
reaction occurs, escalate the rate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.
o Subsequent infusions (in 500 mL): Infuse at 100 mL/hr. Escalate only if there were no Grade 1 (mild)
or greater infusion reactions during a final infusion rate of ≥ 100 mL/hr in the first two infusions.
Escalate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.


Treatment Medications for Day 22:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• daratumumab (Darzalex) __________mg (16 mg/kg) IV once. Allow infusion to come to room temperature
prior to administration. Administer with a 0.22 micrometer filter.
o First infusion (in 1000 mL): initial infusion rate is 50 mL/hr. If no infusion reactions, may increase rate
by 50 mL/hr every hour to a maximum rate to 200 mL/hr.
o Second infusion (in 500 mL): Infuse at 50 mL/hr for the first hour. Escalate the rate only if there were
no grade 1 (mild) or greater infusion reactions during the first 3 hours of the first infusion. If no infusion
reaction occurs, escalate the rate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.
o Subsequent infusions (in 500 mL): Infuse at 100 mL/hr. Escalate only if there were no Grade 1 (mild)
or greater infusion reactions during a final infusion rate of ≥ 100 mL/hr in the first two infusions.
Escalate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.



VER: 09-21-17 (6105 VER: 09-20-17) Cycle 1 & 2; Page 4 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Conditional Orders
Give as needed during daratumumab infusion
• acetaminophen (Tylenol) 650 mg by mouth every 4 hours PRN for 2 doses to prevent infusion reactions. No
more than 4 grams acetaminophen per 24 hours for adults.
• diphenhydramine (Benadryl) 25 mg by mouth every 4 hours PRN for 2 doses to prevent infusion reactions.

Other Orders for Daratumumab Treatment Days:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #64, Refills: 1
Take 5 tablets (20 mg) by mouth in the AM of 1
st
two doses of daratumumab then take 3 tablets (12 mg) in the
AM of 3
rd
and remaining doses of daratumumab. Take 1 tablet (4 mg) daily on the 1
st
and 2
nd
day after each
daratumumab dose.

• diphenhydramine (Benadryl) 25 mg capsule, Disp. Available OTC
Take 1 capsule (25 mg) to 2 capsules (50 mg) by mouth as needed for infusion reaction (may occur up to 4
hours after infusion ends).

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 11
Take 1 tablet (400 mg) by mouth two times daily. Continue for 3 months following treatment.

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

 Other:


Follow Up
• Chemotherapy: Cycle 1 and 2: Day 1, 8, 15, and 22 every 28 days
Cycle 3, 4, 5 and 6: Day 1 and 15 every 28 days
Cycle ≥ 7: Day 1 every 28 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 #: ________

VER: 09-21-17 (6105 VER: 09-20-17) Cycle 3, 4, 5 & 6; Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Daratumumab – Cycle 3, 4, 5 and 6 ONLY
Disease Group: Hematology
Disease: Multiple Myeloma (Advanced)

Therapy:
Cycle 1 to 2: daratumumab 16 mg/kg IV Day 1, 8, 15 and 22

Cycle 3 to 6: daratumumab 16 mg/kg IV Day 1 and 15

Cycle ≥ 7: daratumumab 16 mg/kg IV Day 1

Cycle Length: 28 days Course: until disease progression

Note to all Staff: Chemotherapy Council approved for patients who have received at least three prior therapies,
including a proteasome inhibitor and immunomodulatory agents or who are double refractory to a proteasome
inhibitor and immunomodulatory agent.

Reference(s): Lokhorst HM, et al. N Engl J Med 2015;373(13):1207-19.
de Weers M, et al. J Immunol 2011;186(3):1840-1848.
DARZALEX (Daratumumab) [package insert]. Horsham, PA; Janssen Biotech, Inc; November 2015.
NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. Version 3.2016. Updated Janauary 15, 2016.
Accessed April 18, 2016. http://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 15 (date) ___________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Glucose, Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline
Phosphatase, Total Bilirubin
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 75K/µL or Hemoglobin < 7.5 g/dL or
Creatinine > 2 X ULN or ALT > 3.5 X ULN or Alkaline Phosphatase > 3.5 X ULN or Total Bilirubin > 2.5 X ULN
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Monitor vital signs every 30 minutes during daratumumab.
• Instruct patient to pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment. .
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing


VER: 09-21-17 (6105 VER: 09-20-17) Cycle 3, 4, 5 & 6; Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give 60 minutes prior to daratumumab:
• acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 25 mg by mouth once.
• dexamethasone option:
 dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
 dexamethasone (Decadron) 10 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.

Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• daratumumab (Darzalex) __________mg (16 mg/kg) IV once. Allow infusion to come to room temperature
prior to administration. Administer with a 0.22 micrometer filter.
o First infusion (in 1000 mL): initial infusion rate is 50 mL/hr. If no infusion reactions, may increase rate
by 50 mL/hr every hour to a maximum rate to 200 mL/hr.
o Second infusion (in 500 mL): Infuse at 50 mL/hr for the first hour. Escalate the rate only if there were
no grade 1 (mild) or greater infusion reactions during the first 3 hours of the first infusion. If no infusion
reaction occurs, escalate the rate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.
o Subsequent infusions (in 500 mL): Infuse at 100 mL/hr. Escalate only if there were no Grade 1 (mild)
or greater infusion reactions during a final infusion rate of ≥ 100 mL/hr in the first two infusions.
Escalate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.


Treatment Medications for Day 15:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• daratumumab (Darzalex) __________mg (16 mg/kg) IV once. Allow infusion to come to room temperature
prior to administration. Administer with a 0.22 micrometer filter.
o First infusion (in 1000 mL): initial infusion rate is 50 mL/hr. If no infusion reactions, may increase rate
by 50 mL/hr every hour to a maximum rate to 200 mL/hr.
o Second infusion (in 500 mL): Infuse at 50 mL/hr for the first hour. Escalate the rate only if there were
no grade 1 (mild) or greater infusion reactions during the first 3 hours of the first infusion. If no infusion
reaction occurs, escalate the rate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.
o Subsequent infusions (in 500 mL): Infuse at 100 mL/hr. Escalate only if there were no Grade 1 (mild)
or greater infusion reactions during a final infusion rate of ≥ 100 mL/hr in the first two infusions.
Escalate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.


Conditional Orders
Give as needed during daratumumab infusion
• acetaminophen (Tylenol) 650 mg by mouth every 4 hours PRN for 2 doses to prevent infusion reactions. No
more than 4 grams acetaminophen per 24 hours for adults.
• diphenhydramine (Benadryl) 25 mg by mouth every 4 hours PRN for 2 doses to prevent infusion reactions.


VER: 09-21-17 (6105 VER: 09-20-17) Cycle 3, 4, 5 & 6; Page 3 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Other Orders for Daratumumab Treatment Days:




Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #50, Refills: 1 – review for adequate supply

• diphenhydramine (Benadryl) 25 mg capsule, Disp. Available OTC – review for adequate supply

 Other:




Follow Up
• Chemotherapy: Cycle 3, 4, 5 and 6: Day 1 and 15 every 28 days
Cycle ≥ 7: Day 1 every 28 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 #: ________

VER: 09-21-17 (6105 VER: 09-20-17) Cycle 7+; Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Daratumumab – Cycle ≥ 7 ONLY
Disease Group: Hematology
Disease: Multiple Myeloma (Advanced)

Therapy:
Cycle 1 to 2: daratumumab 16 mg/kg IV Day 1, 8, 15 and 22

Cycle 3 to 6: daratumumab 16 mg/kg IV Day 1 and 15

Cycle ≥ 7: daratumumab 16 mg/kg IV Day 1

Cycle Length: 28 days Course: until disease progression

Note to all Staff: Chemotherapy Council approved for patients who have received at least three prior therapies,
including a proteasome inhibitor and immunomodulatory agents or who are double refractory to a proteasome
inhibitor and immunomodulatory agent.

Reference(s): Lokhorst HM, et al. N Engl J Med 2015;373(13):1207-19.
de Weers M, et al. J Immunol 2011;186(3):1840-1848.
DARZALEX (Daratumumab) [package insert]. Horsham, PA; Janssen Biotech, Inc; November 2015.
NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. Version 3.2016. Updated Janauary 15, 2016.
Accessed April 18, 2016. http://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Glucose, Creatinine, ALT, Alkaline Phosphatase, Total Bilirubin
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC without DIFF, ANC, Creatinine, ALT, Alkaline
Phosphatase, Total Bilirubin
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 75K/µL or Hemoglobin < 7.5 g/dL or
Creatinine > 2 X ULN or ALT > 3.5 X ULN or Alkaline Phosphatase > 3.5 X ULN or Total Bilirubin > 2.5 X ULN
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Monitor vital signs every 30 minutes during daratumumab.
• Instruct patient to pick up dexamethasone (steroid) and diphenhydramine from the pharmacy directly after their
chemotherapy appointment. .
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing


VER: 09-21-17 (6105 VER: 09-20-17) Cycle 7+; Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give 60 minutes prior to daratumumab:
• acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 25 mg by mouth once
• dexamethasone option:
 dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
 dexamethasone (Decadron) 10 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.



Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• daratumumab (Darzalex) __________mg (16 mg/kg) IV once. Allow infusion to come to room temperature
prior to administration. Administer with a 0.22 micrometer filter.
o First infusion (in 1000 mL): initial infusion rate is 50 mL/hr. If no infusion reactions, may increase rate
by 50 mL/hr every hour to a maximum rate to 200 mL/hr.
o Second infusion (in 500 mL): Infuse at 50 mL/hr for the first hour. Escalate the rate only if there were
no grade 1 (mild) or greater infusion reactions during the first 3 hours of the first infusion. If no infusion
reaction occurs, escalate the rate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.
o Subsequent infusions (in 500 mL): Infuse at 100 mL/hr. Escalate only if there were no Grade 1 (mild)
or greater infusion reactions during a final infusion rate of ≥ 100 mL/hr in the first two infusions.
Escalate by 50 mL/hr every hour to a maximum rate of 200 mL/hr.


Conditional Orders
Give as needed during daratumumab infusion
• acetaminophen (Tylenol) 650 mg by mouth every 4 hours PRN for 2 doses to prevent infusion reactions. No
more than 4 grams acetaminophen per 24 hours for adults.
• diphenhydramine (Benadryl) 25 mg by mouth every 4 hours PRN for 2 doses to prevent infusion reactions.


Other Orders for Daratumumab Treatment Days:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #50, Refills: 1 – review for adequate supply

• diphenhydramine (Benadryl) 25 mg capsule, Disp. Available OTC – review for adequate supply

 Other:




VER: 09-21-17 (6105 VER: 09-20-17) Cycle 7+; Page 3 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Cycle ≥ 7: Day 1 every 28 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 #: ________