/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/ppo/,

/clinical/cckm-tools/content/ppo/name-115710-en.cckm

201704111

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Preprinted Paper Orders

Head-Neck Pembrolizumab(21D1) (6154 VER: 12-27-16)

Head-Neck Pembrolizumab(21D1) (6154 VER: 12-27-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 04-20-17 (6154 VER: 12-27-16) Page 1 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Pembrolizumab
Disease Group: Head/Neck
Disease: Head and Neck Squamous Cell Carcinoma (Advanced)

Therapy: pembrolizumab 200 mg IV Day 1

Cycle Length: 21 days Course: until disease progression or maximum 24 months in patients without
disease progression

Reference(s): Seiwert TY, et al. Lancet Oncol 2016;17(7):956-65;
Chow LQM, et al. J Clin Oncol 2016;34(32):3838-45

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: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Creatinine > 1.5 X ULN or AST > 2.5 X
ULN (or > 5 X ULN if known liver metastases) or ALT > 2.5 X ULN (or > 5 X ULN if known liver metastases) or
Total Bilirubin > 1.5 X ULN

Nursing Procedure, Assessment and Monitoring:
• Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any
symptoms of hypotension.
• Monitor blood pressure, heart rate, temperature, respiratory rate and pain level every 15 minutes during
pembrolizumab infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level
30 minutes after first pembrolizumab dose.
• 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 prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:

VER: 04-20-17 (6154 VER: 12-27-16) 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:


• pembrolizumab (Keytruda) 200 mg IV once over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer
other drugs through same infusion line. Hypersensitivity risk. For first and second dose, patient should be
treated in a location to optimize emergency care. Patient must be monitored for 30 minutes after first dose.


Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during 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.

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

 Other:



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 #: ________