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HEM Carfilzomib(28D:1,2,8,9,15,16) (4967 VER: 10-23-15)

HEM Carfilzomib(28D:1,2,8,9,15,16) (4967 VER: 10-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-22-16 (4967 VER: 10-23-15) Page 1 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carfilzomib
Disease Group: Hematology
Disease: Multiple Myeloma (Advanced)

Therapy:
Cycle 1: carfilzomib 20 mg/m2 IV Days 1, 2, 8, 9, 15, 16

Cycle ≥ 2: carfilzomib 27 mg/m2 IV Days 1, 2, 8, 9, 15, 16

Cycle Length: 28 days Course: until disease progression

NOTE: maximum BSA = 2.2 m2 (per physician discretion)

Reference(s): Siegel DS, et al. Blood 2010;116(21):985

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 2 (date) ___________
 Day 8 (date) ___________  Day 9 (date) ___________
 Day 15 (date) __________  Day 16 (date) __________
Pre labs:
• Day 1: Obtain CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC, ANC, Total Bilirubin, AST, ALT
• Hold and notify authorizing provider for:
 Cycle 1 Day 1: ANC < 1000/µL or Platelets < 100K/µL or AST ≥ 3 X ULN or ALT ≥ 3 X ULN or Total Bilirubin
≥ 2 X ULN.
 Cycle ≥ 2 Day 1: ANC < 1000/µL or Platelets < 100K/µL or Creatinine increase ≥ 2 X baseline or AST ≥ 3 X
ULN or ALT ≥ 3 X ULN or Total Bilirubin ≥ 2 X ULN.

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

Hydration/Fluids:
• Cycle 1: sodium chloride 0.9% IV administer 250 to 500 mL prior to treatment.
• Cycle ≥ 2: sodium chloride 0.9% IV administer 250 to 500 mL prior to treatment if needed.



VER: 09-22-16 (4967 VER: 10-23-15) Page 2 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *Cycle 1 and 2: dexamethasone (Decadron) 20 mg by mouth once. PO preferred – may give 20 mg IV if unable
to tolerate PO.
 Other:


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:




 Cycle 1
• carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.


 Cycle ≥ 2
• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.

Treatment Medications for Day 2: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



 Cycle 1
• carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.


 Cycle ≥ 2
• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.

Treatment Medications (continued on next page)

VER: 09-22-16 (4967 VER: 10-23-15) Page 3 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:




 Cycle 1
• carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.


 Cycle ≥ 2
• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.



Treatment Medications for Day 9: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:




 Cycle 1
• carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.


 Cycle ≥ 2
• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.






Treatment Medications (continued on next page)

VER: 09-22-16 (4967 VER: 10-23-15) Page 4 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

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:




 Cycle 1
• carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.


 Cycle ≥ 2
• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.



Treatment Medications for Day 16: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:




 Cycle 1
• carfilzomib (Kyprolis) ____________ mg (20 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.


 Cycle ≥ 2
• carfilzomib (Kyprolis) ____________ mg (27 mg/m2) IV once over 2 to 10 minutes. Hypersensitivity to
carfilzomib can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Monitor patient for hypotension and shortness of breath. Maximum BSA = 2.2m2 (per
physician discretion). Do not administer as an infusion with other medicinal products. The intravenous line
should be flushed with normal saline or dextrose 5% immediately before and after carfilzomib administration.



VER: 09-22-16 (4967 VER: 10-23-15) Page 5 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Conditional Orders Day 1, 2, 8, 9, 15, and 16:
• sodium chloride 0.9% IV administer 250 to 500 mL if patient becomes hypotensive.

Other Orders for Day 1, 2, 8, 9, 15, and/or 16:



Take Home Medications
• 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.

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth 2 times daily.

 Other:


Follow Up
• Chemotherapy: Day 1, 2, 8, 9, 15 and 16 every 28 days

• Labs: None
 Other:


• Procedures/Imaging/Scans:








• Other Orders:






MD Signature_____________________________ Pager______________
Date _____________Time_____________

Order verification:
RN Signature: ___________________________________ Date: ___________ Time: ______ Pager #: ________
RPh Signature: __________________________________ Date: ___________ Time: ______ Pager #: ________