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Lung Nivolumab (28D:1,15) (5601 VER: 10-25-17)

Lung Nivolumab (28D:1,15) (5601 VER: 10-25-17) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 10-26-17 (5601 VER: 10-25-17) Page 1 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Nivolumab
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Advanced)

Therapy: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg)

Cycle Length: 28 days Course: until disease progression

Note: A baseline chest X-ray is recommended prior to initiation of this agent due to the risk of developing
pneumonitis.

Reference(s): Rizvi NA, et al. Lancet Oncol 2015;16:257-65.
http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm520871.htm. Accessed Dec 19, 2016.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs: Obtain the following:
• Day 1 and 15: CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total
Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase
• Cycle 1, Day 1 and Day 1 every EVEN cycle only: TSH, Free T4
• Cycle 1, Day 1 only: Urine pregnancy test (for women of childbearing potential)
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1 and 15: Verify the following labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin,
Amylase, Lipase
• Day 1 and 15: Hold and notify authorizing provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Creatinine >
1.5 X ULN or AST > 2.5 X ULN (> 5 X ULN if known liver metastasis) or ALT > 2.5 X ULN (> 5 X ULN if known
liver metastasis) or Total Bilirubin > 1.5 X ULN or Amylase ≥ 1.6 X ULN or Lipase ≥ 1.6 X ULN

Nursing Procedure, Assessment and Monitoring:
• Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or
shortness of breath) or colitis (abdominal pain, mucus or blood in stool).
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:



Final Approved VER: 10-26-17 (5601 VER: 10-25-17) Page 2 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:

• nivolumab (Opdivo) ____________ mg (3 mg/kg) IV once over 30 minutes. Maximum dose = 240 mg.
Administer with low protein, in line 0.2 or 0.22 micron filter. Do not shake. Do not co-infuse with other
medications through same infusion line. Hypersensitivity to nivolumab can occur. For first and second dose,
patient should be treated in a location to optimize emergency care.

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:

• nivolumab (Opdivo) ____________ mg (3 mg/kg) IV once over 30 minutes. Maximum dose = 240 mg.
Administer with low protein, in line 0.2 or 0.22 micron filter. Do not shake. Do not co-infuse with other
medications through same infusion line. Hypersensitivity to nivolumab can occur. For first and second dose,
patient should be treated in a location to optimize emergency care.

Other Orders for Day 1 and/or 15:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• 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.

 Other:


Follow Up
• Chemotherapy: Day 1 and 15 every 28 days

• Labs:
 Other:

• Procedures/Imaging/Scans:


• Other Orders:


MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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