OP FULVESTRANT (INITIAL AND MAINTENANCE) INJECTION		version 2/27/2025		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☑	Referral to IV Infusion Room Appointment request for initial dose.	Once	S	1 treatment	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment request for initial dose.		
	☑	Referral to IV Infusion Room Appointment request for second dose.	Once	S+14	1 treatment	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment request for second dose.		
	☑	Referral to IV Infusion Room Appointment request for third dose.	Once	S+28	1 treatment	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment request for third dose.		
	☑	Referral to IV Infusion Room Appointment request for subsequent doses.	Every 4 weeks	S+55	 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment request for subsequent doses.		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	Comprehensive metabolic panel	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	CBC with platelet and differential	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Magnesium level	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Urinalysis, automated with microscopy	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Cancer antigen 27-29 (CA BR)	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Miscellaneous referral test	Every visit	S	Until discont'd	
		STAT, Status: Future, Expected: S, Expires: S+365, Clinic Collect		
	☐	Potassium Replacement Protocol	Every visit	S	Until discont'd	
		The protocol applies only if the following is met. 
	1. SCr LESS than 1.5; 
	2. Potassium level LESS than 3.5 mEq/L; 
	3. Recent pre-infusion labs.   
	
	Dosing is based on lab value.
	o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
	o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
	o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
	o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 
	
	If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
	Sign electrolyte replacement order as Per protocol: cosign required.		
	☐	Magnesium Replacement Protocol	Every visit	S	Until discont'd	
		The protocol applies only if the following is met. 
	1. SCr LESS than 1.5; 
	2. Magnesium level LESS than 1.6 mg/dL; 
	3. Recent pre-infusion labs. 
	
	Dosing is based on lab value. 
	o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
	o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
	o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
	o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 
	
	If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
	Sign electrolyte replacement order as Per protocol: cosign required.		

Medications 	

	
	Interval	Defer Until	Duration	
	☐	fulvestrant (FASLODEX) INTRAMUSCULAR injection 500 mg	Once	S	1 treatment	
		500 mg, intramuscular, once, Starting when released
	For IM administration ONLY.
	Administer 500 mg dose as two 5 mL IM injections (One in each buttocks- gluteal area) slowly over 1-2 minutes per injection		
	☐	fulvestrant (FASLODEX) INTRAMUSCULAR injection 500 mg	Once	S+14	1 treatment	
		500 mg, intramuscular, once, Starting when released
	For IM administration ONLY.
	Administer 500 mg dose as two 5 mL IM injections (One in each buttocks- gluteal area) slowly over 1-2 minutes per injection		
	☐	fulvestrant (FASLODEX) INTRAMUSCULAR injection 500 mg	Once	S+28	1 treatment	
		500 mg, intramuscular, once, Starting when released
	For IM administration ONLY.
	Administer 500 mg dose as two 5 mL IM injections (One in each buttocks- gluteal area) slowly over 1-2 minutes per injection		
	☐	fulvestrant (FASLODEX) INTRAMUSCULAR injection 500 mg	Every 4 weeks	S+55	Until discont'd	
		500 mg, intramuscular, once, Starting when released
	For IM administration ONLY.
	Administer 500 mg dose as two 5 mL IM injections (One in each buttocks- gluteal area) slowly over 1-2 minutes per injection		

Hematology & Oncology Hypersensitivity Reaction Standing Order 	

	
	Interval	Defer Until	Duration	
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Every visit	S	Until discont'd	
		25 mg, intravenous, PRN, Allergic reaction, Starting when released, Until Discontinued		
	☐	famotidine (PEPCID) injection 20 mg	Every visit	S	Until discont'd	
		20 mg, intravenous, PRN, Allergic reaction, Starting when released, Until Discontinued		
	☐	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Every visit	S	Until discont'd	
		100 mg, intravenous, PRN, Allergic reaction, Starting when released, Until Discontinued		
	☐	dexAMETHasone (DECADRON) IV 4 mg	Every visit	S	Until discont'd	
		4 mg, intravenous, PRN, Allergic reaction, Starting when released, Until Discontinued		
	☐	epINEPHrine (ADRENALIN) injection 1 mg/mL	Every visit	S	Until discont'd	
		0.3 mg, subcutaneous, PRN, anaphylaxis, Starting when released, Until Discontinued		
	☐	cetirizine (ZyrTEC) tablet 10 mg				
		10 mg, oral, PRN, Allergic reaction, Starting when released, Until Discontinued