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HEM Bortezomib(21D:1,4,8,11)/Dexamethasone(21D:1,8,15)/Lenalidomide(21D:1-14) (3535 VER: 06-03-13/CC: 10-23-15)

HEM Bortezomib(21D:1,4,8,11)/Dexamethasone(21D:1,8,15)/Lenalidomide(21D:1-14) (3535 VER: 06-03-13/CC: 10-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-23-15 (3535 VER: 06-03-13/CC: 10-23-15) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bortezomib/Lenalidomide/Dexamethasone (VRD)
Disease Group: Hematology
Disease: Multiple Myeloma

Therapy: dexamethasone 40 mg by mouth Day 1, 8, and 15,
bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11,
lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14
NOTE: Thrombosis prophylaxis recommended for all patients.

Cycle Length: 21 days Course: up to 8 cycles

Note to All Staff: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must indicate treatment
plan modification noting deletion of Day 4 and 11 in treatment medication orders section.

Reference(s): Richardson P, et al. Blood 2008;112:Abstract 92; Richardson P, et al. Blood 2008;112:Abstract
1742; Moreau P, et al. Lancet Oncol 2011;12:431-40.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 4 (date) ___________
 Day 8 (date) ___________  Day 11 (date) ___________
Pre labs:
• Day 1: Obtain CBC with DIFF, Creatinine, Total Bilirubin, AST
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST
• Cycle 1, Day 1 and 8: Urine pregnancy test (for women of childbearing potential)
• Cycle 2+, Day 1: Urine pregnancy test (for women of childbearing potential)
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 70K/µL or Creatinine Clearance < 60 mL/min
or Total Bilirubin ≥ 1.5 x ULN or AST ≥ 2.5 x ULN.

Nursing Procedure, Assessment and Monitoring: Flush/Line Care per Institution standards

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

Premedications/Antiemetics: None
 Other:








Final Approved VER: 12-23-15 (3535 VER: 06-03-13/CC: 10-23-15) Page 2 of 4
Copyright © 2016 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:


• bortezomib (Velcade) __________mg (1.3 mg/m2) subcutaneous once.

• dexamethasone (Decadron) and lenalidomide (Revlimid) – See Take Home Medications

Treatment Medications for Day 4: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below.
Indicate if Day 4 bortezomib to be omitted:


• bortezomib (Velcade) __________mg (1.3 mg/m2) subcutaneous once.

• dexamethasone (Decadron) and lenalidomide (Revlimid) – See Take Home Medications

Treatment Medications for Day 8: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________mg (1.3 mg/m2) subcutaneous once.

• dexamethasone (Decadron) and lenalidomide (Revlimid) – See Take Home Medications

Treatment Medications for Day 11: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below.
Indicate if Day 11 bortezomib to be omitted.


• bortezomib (Velcade) __________mg (1.3 mg/m2) subcutaneous once.

• dexamethasone (Decadron) and lenalidomide (Revlimid) – See Take Home Medications


Other Orders for Day 1, 4, 8 and/or 11:







Final Approved VER: 12-23-15 (3535 VER: 06-03-13/CC: 10-23-15) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #30, Refills: 7
Take 10 tablets (40 mg) by mouth once per week on Day 1, 8, and 15.

• lenalidomide (Revlimid) _________ mg (available as 5 mg, 10 mg, 15 mg, 25 mg capsules)
Disp. # __________, Refills: 0; Verify compliance with Revlimid REMS Program.

Take ___________ mg by mouth once daily on Day 1 through 14.

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

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 7
Take 1 tablet (400 mg) by mouth 2 times daily.

• Thrombosis Prophylaxis:
 aspirin 325 mg EC tablet, Disp. Available OTC
Take 1 tablet (325 mg) by mouth one time daily.

 enoxaparin (Lovenox) 40 mg/0.4 mL injection, Disp. #30, Refills: 11
Inject 40 mg under skin one time daily.

 warfarin (Coumadin) 5 mg tablet, Disp. #30, Refills: 11
Take 1 tablet (5 mg) by mouth one time daily.


 Other:



Follow Up
• Chemotherapy: Day 1, 4, 8 and 11 every 21 days

• Labs:
Cycle 1, Day 15: Urine pregnancy test (for women of childbearing potential)
Cycle 2+, Day 15: Urine pregnancy test if periods are irregular (for women of childbearing potential)

 Other:



• Procedures/Imaging/Scans:





• Other Orders:



Final Approved VER: 12-23-15 (3535 VER: 06-03-13/CC: 10-23-15) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
MD Signature_________________________________________ Pager______________
Date __________________Time___________________



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