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HEM CLL Chlorambucil (28D1,15)/Obinutuzumab (5522 VER: 09-15-15)

HEM CLL Chlorambucil (28D1,15)/Obinutuzumab (5522 VER: 09-15-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-15-15 (5522 VER: 09-15-15) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Chlorambucil/Obinutuzumab
Disease Group: Hematology
Disease: Chronic Lymphocytic Leukemia
Therapy:
Cycle 1:
obinutuzumab 100 mg IV Day 1,
obinutuzumab 900 mg IV Day 2,
obinutuzumab 1000 mg IV Day 8 and 15,
chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15
Cycles ≥ 2:
obinutuzumab 1000 mg IV Day 1,
chlorambucil 0.5 mg/kg by mouth once daily on Day 1 and 15

Cycle Length: 28 days Course: 6 cycles

Note (1): Reactivation of hepatitis B virus (HBV) may occur with use of obinutuzumab, in some cases resulting in
fulminant hepatitis, hepatic failure and death. Screen all patients for HBV infection before treatment initiation.

Note (2): Consider withholding antihypertensive medications for 12 hours prior to and throughout each
obinutuzumab infusion and for the first hour after administration.

Reference(s): Goede V, et al. N Engl J Med 2014;370(12):1101-10; Lee H, et al. Clin Cancer Res 2014;20(16):3902-7

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 2 (date) ___________
 Day 8 (date) ___________  Day 15 (date) ___________

Pre labs:
Cycle 1:
• Day 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total
Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Uric Acid, Phosphate, Total Hepatitis B Core AB, Hepatitis B
Surface AG
 Other:

• Day 2: Obtain Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Phosphate, LDH
 Other:

• Day 8: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid
 Other:

• Day 15: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid
 Other:

Cycle 2 through 6:
• Day 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, LDH
 Other:

Final Approved VER: 12-15-15 (5522 VER: 09-15-15) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF
• Hold and notify provider for:
 Day 1: ANC < 1000/µL or Platelets < 50K/µL

Nursing Procedure, Assessment and Monitoring:
• Vital signs every 15 minutes for the first hour during infusion, then every hour until the end of infusion.
• Flush/Line Care per Institution standards

Hydration/Fluids:
Cycle 1 (Day 1 and 2):
 sodium chloride 0.9% IV to establish line and for flushing
 sodium chloride 0.9% IV once infuse 1000 mL throughout treatment

Cycle 1 (Day 8 and 15) and Cycle 2 through 6:
• sodium chloride 0.9% IV to establish line and for flushing


Premedications/Antiemetics
Cycle 1 (Day 1 and 2) give prior to obinutuzumab:
• Dexamethasone (Decadron) 20 mg IV once. Administer at least 60 minutes prior to infusion.
• Acetaminophen (Tylenol) 650 mg by mouth once.
• Diphenhydramine (Benadryl) 50 mg by mouth once

Cycle 1 (Day 8 and 15) and Cycles 2 through 6 give prior to obinutuzumab:
• Acetaminophen (Tylenol) 650 mg by mouth once.
• Dexamethasone (Decadron) 20 mg IV once. Administer at least 60 minutes prior to infusion. For patients with
previous severe infusion reaction or lymphocyte count greater than 25K/µL.
• Diphenhydramine (Benadryl) 50 mg by mouth once. For patients with previous infusion reaction.

Treatment Medications for Day 1:
Cycle 1:
• obinutuzumab (Gazyva) 100 mg IV once. Administer at 25 mg/hr (28.5 mL/hr) over 4 hours. DO NOT increase
infusion rate.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• See Take Home Medication Section for chlorambucil

Cycle 2 through 6:
• obinutuzumab (Gazyva) 1000 mg IV once. Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and
can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30 minutes to a maximum rate of 400 mg/hr
(126 mL/hr).
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• See Take Home Medication Section for chlorambucil



Final Approved VER: 12-15-15 (5522 VER: 09-15-15) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 2 (Cycle 1 only):
• obinutuzumab (Gazyva) 900 mg IV once. Administer at 50 mg/hr (17.3 mL/hr). The rate of infusion can be
escalated in increments of 50 mg/hr (17.3 mL/hr) every 30 minutes to a maximum rate of 400 mg/hr (138.3
mL/hr).
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

Treatment Medications for Day 8 (Cycle 1 only):
• obinutuzumab (Gazyva) 1000 mg IV once. Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and
can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30 minutes to a maximum rate of 400 mg/hr
(126 mL/hr).
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

Treatment Medications for Day 15 (Cycle 1 only):
• obinutuzumab (Gazyva) 1000 mg IV once. Infusions can be started at a rate of 100 mg/hr (31.5 mL/hr) and
can be escalated in increments of 100 mg/hr (31.5 mL/hr) every 30 minutes to a maximum rate of 400 mg/hr
(126 mL/hr).
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• See Take Home Medication Section for chlorambucil

Other Orders for Day 1, 2, 8 and 15:







Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• chlorambucil (Leukeran) 2 mg tablet, Disp. #____, Refills: 0, Dosing based on 0.5 mg/kg/day
Take ____ tablets ( _____ mg) by mouth once daily on Days 1 and 15. Take on empty stomach.

• allopurinol (Zyloprim) 300 mg tablet, Disp. #7, Refills: 0
Take 1 tablet (300 mg) by mouth once daily for 7 days of Cycle 1. Start 1 day prior to 1
st
obinutuzumab dose.

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

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

 Other:





Final Approved VER: 12-15-15 (5522 VER: 09-15-15) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Follow Up
• Chemotherapy:
Cycle 1: Day 2, 8 and 15.
Cycles 2 through 6: 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 #: ________