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HEM Nilotinib(28D:1-28) (1889 VER: 11-23-15)

HEM Nilotinib(28D:1-28) (1889 VER: 11-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 02-25-16 (1889 VER: 11-23-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Nilotinib
Disease Group: Hematology
Disease: Chronic Myelogenous Leukemia (Chronic, Resistant or Accelerated/blast phase)/ Acute Lymphoblastic
Leukemia

Therapy for Chronic Myelogenous Leukemia (Chronic): nilotinib 300 mg by mouth twice daily,
Therapy for Chronic Myelogenous Leukemia (Resistant or Accelerated/blast phase)/ Acute
Lymphoblastic Leukemia: nilotinib 400 mg by mouth twice daily,

Cycle Length: Cycle 1 through 3 = 28 days; Cycles 4+ may be extended to 84 days

Course: until disease progression

Note to all Staff: Nilotinib prolongs the QT interval and caution should be used in patients with hypokalemia,
hypomagnesemia or long QT syndrome as sudden death has been reported in these patients. Correct
hypokalemia and hypomagnesemia prior to initiation of therapy and monitor electrolytes periodically. ECGs are
recommended to monitor the QTc at baseline, 7 days after initiation, periodically as clinically indicated, and
following dose adjustments. Dose modify per package insert for QTc greater than 480 msec. Avoid the use of
QT-prolonging agents and strong CYP3A4 inhibitors.

Note to all Staff (2): Nilotinib needs an acidic stomach environment for absorption.

Reference(s): Saglio G, et al. N Engl J Med 2010; 362:2251-2259; Kantarjian HM, et al. Blood 2007; 110(10):
3540-6

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1: Obtain CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Amylase, Lipase
 Other:





• Cycle 2+: Obtain CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
 Other:




Final Approved VER: 02-25-16 (1889 VER: 11-23-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, AST,
ALT, Alkaline Phosphatase
• Hold and notify provider for:
 Cycle 1: ANC < 1000/µL or Platelets < 75K/µL or Potassium < 3.5 mmol/L or Magnesium < 1.7 mg/dL or
Total Bilirubin > 4 mg/dL or AST or ALT > 2.5 X ULN or Amylase > 2.5 X ULN or Lipase 2.5 X ULN.
 Cycle 2+: ANC < 1000/µL or Platelets < 75K/µL or Potassium < 3.5 mmol/L or Magnesium < 1.7 mg/dL or
Total Bilirubin > 4 mg/dL or AST or ALT > 2.5 X ULN Cycle 1, Day 1: Verify that baseline ECG obtained.

Nursing Procedure, Assessment and Monitoring:
• Remind patient that nilotinib needs an acidic stomach environment for absorption.
• Flush/Line Care per Institution standards

Hydration/Fluids: None

Premedications/Antiemetics: None

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



• See Take Home Medication Section




Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
 nilotinib (Tasigna) 150 mg capsule, Disp. #_________ (order qty in multiples of 28 capsules) , Refills: _____
Take ______ capsule (_________ mg) by mouth in AM and ______ capsule (_________ mg) by mouth in PM.
Swallow whole. Take on empty stomach. Do not take with grapefruit products.



 nilotinib (Tasigna) 200 mg capsule, Disp. #_________ (order qty in multiples of 28 capsules) , Refills: _____
Take ______ capsule (_________ mg) by mouth in AM and ______ capsule (_________ mg) by mouth in PM.
Swallow whole. Take on empty stomach. Do not take with grapefruit products.

 Other:




Final Approved VER: 02-25-16 (1889 VER: 11-23-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 every  28 days or  84 days

• Labs:
 Other:






• Procedures/Imaging/Scans:
 Cycle 1, Day 7: ECG for QTc evaluation (ECG required 7 days following therapy initiation)















• Other Orders:












MD Signature_________________________________________ Pager______________
Date __________________Time___________________

Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________