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HEM Idelalisib (28D1-28) (5194 VER: 10-31-14)

HEM Idelalisib (28D1-28) (5194 VER: 10-31-14) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 09-17-15 (5194 VER: 10-31-14) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Idelalisib
Disease Group: Hematology
Disease: Relapsed/Refractory Follicular Lymphoma, Small Lymphocytic Lymphoma, Chronic Lymphocytic
Leukemia

Therapy: idelalisib 150 mg by mouth twice daily continuously

Cycle Length: 28 days Course: until disease progression

Reference(s): Flinn I, et al. Blood 2014;123(22):3406-13

Note to All Staff: Fatal and/or serious hepatotoxicity has occurred in patients receiving idelalisib. Monitor
hepatic function prior to and during treatment.

Fatal and/or serious diarrhea or colitis has occurred in patients receiving idelalisib. Monitor for the development
of severe diarrhea or colitis.

Fatal and serious pneumonitis can occur in patients receiving idelalisib. Monitor patients for pulmonary
symptoms and bilateral interstitial infiltrates.

Fatal and serious intestinal perforation can occur in patients receiving idelalisib. Monitor patients for abdominal
pain, chills, fever, nausea, or vomiting.


Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1, Day 1: Obtain CBC with DIFF, Total Bilirubin, AST, ALT, Creatinine, Uric Acid, Calcium, Magnesium,
Phosphate, LDH, Serum Pregnancy Test (for women of childbearing potential)
• Cycle 2+, Day 1: Obtain CBC with DIFF, Total Bilirubin, AST, ALT, Serum 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: CBC with DIFF, Total Bilirubin, AST, ALT
• Hold and notify provider for: ANC < 500/µL or Platelets < 25K/µL or ALT > 5 x ULN or AST > 5 x ULN or Total
Bilirubin > 3 x ULN



Final Approved VER: 09-17-15 (5194 VER: 10-31-14) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Nursing Procedure, Assessment and Monitoring:
• Monitor patient for diarrhea and notify provider if patient reports 6 or more bowel movements per day.
• Assess patient for cough, dyspnea, or pulmonary findings on lung exam that would suggest pneumonia or
drug-related pneumonitis.
• Monitor patient for signs and symptoms of intestinal perforation. Advise patients to report any new or
worsening abdominal pain, chills, fever, nausea, or vomiting.
• Instruct patient to monitor for bowel changes and call clinic if they experience 6 or more bowel movements per
day.
• Obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry.
• Flush/Line Care per Institution standards

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

Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• idelalisib (Zydelig) 150 mg tablet, Disp. #60, Refills: 0
Take 1 tablet (150 mg) by mouth two times daily. Take with or without food. Swallow tablets whole.

• 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: 11
Take 1 tablet (400 mg) by mouth two times daily.

• loperamide (Imodium) 2 mg tablet, Disp. Available OTC
Take 2 tablets (4 mg) by mouth with 1
st
loose stool followed by 1 tab every 2 hours or 2 tablets every 4 hours
until no diarrhea for 12 hours. Max dose = 8 tablets/day

 allopurinol (Zyloprim) 300 mg tablet, Disp. #14 Refills: 0
Take 1 tablet (300 mg) by mouth once daily. Take on Days 1 through 14 of Cycle 1 only.

 allopurinol (Zyloprim) 300 mg tablet, Disp. #28 Refills: 0
Take 1 tablet (300 mg) by mouth two times daily. Take on Days 1 through 14 of Cycle 1 only.


 Other:


Final Approved VER: 09-17-15 (5194 VER: 10-31-14) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Clinic Visit: Day 1 every 28 days

• Labs:
 Day 8 (Cycle 1 only) - Obtain CBC with DIFF, Total Bilirubin, ALT, AST, Creatinine, Uric Acid, Calcium,
Magnesium, Phosphate, LDH

 Day 15 (Cycle 1, 2, 3 and 4 only) – Obtain CBC with DIFF, Total Bilirubin, ALT, AST

 Day 22 (Cycle 1 only) – Obtain CBC with DIFF, Total Bilirubin, ALT, AST


 Other:



• Procedures/Imaging/Scans:











• Other Orders:








MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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