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HEM CLL Ibrutinib (28D:1-28) (5227 VER: 10-14-14)

HEM CLL Ibrutinib (28D:1-28) (5227 VER: 10-14-14) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 8-5-15 (5227 VER: 10-14-14) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Ibrutinib
Disease Group: Hematology
Disease: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Therapy: ibrutinib 420 mg by mouth once daily continuously

Cycle Length: 28 days Course: until disease progression

Reference(s): Byrd JC, et al. N Engl J Med 2013;369(1):32-42.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total
Bilirubin, AST, ALT, Alkaline Phosphatase, LDH
• Day 1 (Cycle 1 only): Uric Acid
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, AST, ALT, Total Bilirubin
• Hold and notify provider for:
 Day 1: ANC ≤ 500/µL or Platelets ≤ 50K/µL or AST > 3 X ULN or ALT > 3 X ULN or Total Bilirubin > ULN

Nursing Procedure, Assessment and Monitoring:
• 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


Other Orders for Day 1:






Final Approved VER: 8-5-15 (5227 VER: 10-14-14) 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)
• ibrutinib (Imbruvica) 140 mg capsule, Disp. #90, Refills: ____
Take 3 caps (420 mg) by mouth one time daily. Swallow caps whole with water at approximately the same
time each day. Do not open, break or chew caps.

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

• allopurinol (Zyloprim) 300 mg tablet, Disp. #7 Refills: 0
Take 1 tablet (300 mg) by mouth once daily for 7 days.

 Other:



Follow Up
• Clinic Visit: Day 1 every 28 days

• Labs:
 Day 8 (Cycle 1 only) – Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid
 Other:


 Day 15 (Cycle 1 only) – Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid
 Other:


• Procedures/Imaging/Scans:







• Other Orders:


MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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