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

/clinical/cckm-tools/content/ppo/name-124483-en.cckm

20180124

page

100

UWHC,UWMF,

Tools,

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

Lung Durvalumab(28D:1,15) (6721 Ver 1-22-18)

Lung Durvalumab(28D:1,15) (6721 Ver 1-22-18) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 1-23-18 (6721 VER: 01-22-18) Page 1 of 2
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Durvalumab
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Advanced)

Therapy: durvalumab 10 mg/kg IV Day 1 and 15

Cycle Length: 28 days Course: until disease progression (maximum 12 months)

Reference(s): Antonia SJ, et al. N Engl J Med 2017;377(20):1919-29

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1 and 15: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin,
Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase
• Day 1 every ODD cycle only: TSH, Free T4, Cortisol
• Cycle 1, Day 1 only: Urine pregnancy test (for women of childbearing potential)
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1 and 15: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose
 Day 1 on ODD cycles only: TSH, Free T4, Cortisol
• Hold and notify provider for:
 Day 1 and 15: ANC < 1000/µL or Platelets < 100K/µL or Hemoglobin < 9 g/dL or AST > 2.5 X ULN or ALT
> 2.5 X ULN or Total Bilirubin > 1.5 X ULN or Creatinine > 2 X ULN or Glucose > 250 mg/dL
 Day 1 on ODD cycles only: TSH > ULN or Cortisol ≤ 3 µg/dL



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: 1-23-18 (6721 VER: 01-22-18) Page 2 of 2
Copyright © 2018 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:

• durvalumab (Imfinzi) __________mg (10 mg/kg) IV once over 60 minutes. Administer with low protein, in line
0.2 or 0.22 micron filter. Do not shake. Do not co-infuse with other medications through same infusion line.
Hypersensitivity to durvalumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.


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:

• durvalumab (Imfinzi) __________mg (10 mg/kg) IV once over 60 minutes. Administer with low protein, in line
0.2 or 0.22 micron filter. Do not shake. Do not co-infuse with other medications through same infusion line.
Hypersensitivity to durvalumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.


Other Orders for Day 1 and/or 15:


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.

 Other:


Follow Up
• Chemotherapy: Day 1 and 15 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 #: ________