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HEM Ruxolitinib(28D:1-28) (4863 VER: 11-23-15)

HEM Ruxolitinib(28D:1-28) (4863 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 (4863 VER: 11-23-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Ruxolitinib
Disease Group: Hematology
Disease: Myelofibrosis (Intermediate or High-Risk)

Therapy: ruxolitinib (dose per protocol) by mouth twice daily continuously

Dose per Protocol: The recommended starting dose for patients with platelet count greater than 200K/µL is
ruxolitinib 20 mg by mouth twice daily continuously. The recommended starting dose for patients with platelet
count 100 to 200K/µL is ruxolitinib 15 mg by mouth twice daily continuously.

Note to all Staff: When administering ruxolitinib concurrently with a strong CYP3A4 inhibitor (for example,
ketoconazole, itraconazole, clarithromycin, atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir,
telithromycin, and voriconazole) consider a reduction of ruxolitinib starting dose to 10 mg by mouth twice daily for
patients with a platelet count greater than or equal to 100K/µL.

Cycle Length: 28 days Course: until disease progression or lack of effect after 6 months

Reference(s): Verstovsek S, et al. N Eng J Med. 2012;366(9):799-807; Harrison CN, et al. J Clin Oncol
2011;29(15):(abstract LBA650).

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, BUN, Creatinine, Total Bilirubin, AST, ALT
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: Creatinine, Total Bilirubin
• Hold and notify provider for: Calculated Creatinine Clearance less than 60 mL/min or Total Bilirubin greater
than ULN.

Nursing Procedure, Assessment and Monitoring: None

Hydration/Fluids: None

Premedications/Antiemetics: None

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:


• See Take Home Medication Section

Final Approved VER: 02-25-16 (4863 VER: 11-23-15) Page 2 of 2
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)
• ruxolitinib (Jakafi) __________ mg tablets, Disp. # ________, Refills:0
(available tablet sizes 5 mg, 10 mg, 15 mg and 20 mg)

Take _________ tablets (___________ mg) by mouth two times daily.

NOTE: The recommended starting dose for patients with platelet count greater than 200K/µL is ruxolitinib 20
mg by mouth twice daily continuously. The recommended starting dose for patients with platelet count 100 to
200K/µL is ruxolitinib 15 mg by mouth twice daily continuously.

 Other:



Follow Up
• Chemotherapy: Day 1 every 28 days

• Labs:
 Day 15 – Obtain CBC with DIFF
 Other:


• Procedures/Imaging/Scans:









• Other Orders:





MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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