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Patient Specific Template HEM Dexamethasone(28D:1,8,15,22)/Ixazomib(28D:1,8,15)/Lenalidomide(28D:1-21) (5843 VER: 12-16-15)

Patient Specific Template HEM Dexamethasone(28D:1,8,15,22)/Ixazomib(28D:1,8,15)/Lenalidomide(28D:1-21) (5843 VER: 12-16-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 04-05-16 (Patient Specific Regimen 5843 VER: 12-16-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Patient Specific Regimen - Dexamethasone/Ixazomib/Lenalidomide
Disease Group: Hematology
Disease: Myeloma

Therapy: dexamethasone 40 mg by mouth Day 1, 8, 15 and 22,
ixazomib 4 mg by mouth Day 1, 8, and 15,
lenalidomide 25 mg by mouth once daily Day 1 through 21
NOTE: Thrombosis prophylaxis recommended for all patients.

Cycle Length: 28 days Course: until disease progression

Reference(s): Moreau P, et al. Blood 2015;126(23): Abstract 727.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin, Urine Pregnancy Test (for women of
childbearing potential)
 Other:





Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Total Bilirubin,
Urine Pregnancy Test (for women of childbearing potential)
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 75K/µL or Creatinine Clearance < 60 mL/min
or AST > 3 x ULN or ALT > 3 x ULN or Total Bilirubin > 1.5 x ULN.


Nursing Procedure, Assessment and Monitoring: None


Hydration/Fluids: None

Premedications/Antiemetics: None
 Other:




Final Approved VER: 04-05-16 (Patient Specific Regimen 5843 VER: 12-16-15) Page 2 of 3
Copyright © 2016 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:



• dexamethasone (Decadron), ixazomib (Ninlaro) and lenalidomide (Revlimid) – See Take Home Medications

Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #40, Refills: 0
Take 10 tablets (40 mg) by mouth once per week on Day 1, 8, 15, and 22.

• ixazomib (Ninlaro) 4 mg capsule, Disp. #3, Refills: 0; Note also available as 3 mg and 2.3 mg capsules for
dose reductions.
Take 1 capsule (4 mg) by mouth on day 1, 8, and 15. Take at least 1 hour before or 2 hours after food.

• lenalidomide (Revlimid) 25 mg capsule, Disp. # 21, Refills: 0; Verify compliance with Revlimid REMS Program.
Take 1 capsule (25 mg) by mouth once daily on Day 1 through 21.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 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.

• Thrombosis Prophylaxis:
 aspirin 325 mg EC tablet, Disp. Available OTC
Take 1 tablet (325 mg) by mouth one time daily.

 enoxaparin (Lovenox) 40 mg/0.4 mL injection, Disp. #30, Refills: 11
Inject 40 mg under skin one time daily.

 warfarin (Coumadin) 5 mg tablet, Disp. #30, Refills: 11
Take 1 tablet (5 mg) by mouth one time daily.


 Other:





Final Approved VER: 04-05-16 (Patient Specific Regimen 5843 VER: 12-16-15) 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:
Cycle 1, Day 8, 15 and 22: Urine pregnancy test (for women of childbearing potential)
Cycle 2+, Day 15: For women of childbearing potential with IRREGULAR periods obtain: Urine pregnancy test

 Other:






• Procedures/Imaging/Scans:













• Other Orders:









MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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