TOCILIZUMAB (CABMR) Infusion		version 2/27/2025		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☑	Referral to IV Infusion Room . Therapy Plan #1; Performing Department: HMH TRANSPLT INFUSION; Choose a treatment option: New Therapy Plan; Infusion Medication: tocilizumab; Urgency of Scheduling: Routine	Day 1 of every 1 month, at least 25 days apart	S	 treatments	
		Normal
	. Therapy Plan #1
	Performing Department: HMH TRANSPLT INFUSION
	Choose a treatment option: New Therapy Plan
	Infusion Medication: tocilizumab
	Urgency of Scheduling: Routine		

Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☐	Insert Peripheral IV or Access Portacath	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Vital signs - T/P/R/BP Per Unit Protocol	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Nursing communication: Monitor patient for any signs of MINOR INFUSION REACTION	Every visit	S	Until discont'd	
		Monitor patient for signs of minor infusion reaction; fever, chills, pruritis, uticaria, chest pain, mild hypotension, hypertension, or mild dyspnea. For *MINOR INFUSION REACTION* take the following steps: stop or slow infusion rate by 50%. If symptoms do not resolve within 5-10 minutes give Benadryl as ordered. Notify MD if symptoms do not resolve within 5-10 minutes. With MD approval, give Solu-medrol as ordered. When symptoms resolve, restart medication at 25% of the original rate. After 15-30 minutes gently increase rate and monitor patient closely until completion.		
	☐	Nursing communication: Monitor patient for signs of SEVERE INFUSION REACTION	Every visit	S	Until discont'd	
		Monitor patient for signs of severe infusion reaction: severe dyspnea, wheezing, stridor, angioedema, or marked hypotension. For *SEVERE INFUSION REACTION* take the following steps; STOP Infusion and start normal saline solution. Notify physician and administer Benadryl as ordered. Monitor vital signs. Administer  Epinephrine as ordered. Consult MD for further orders.		
	☐	Nursing communication: Check Triglyceride levels every 6 months and check counts	Every visit	S	Until discont'd	
		No details available for preview		
	☐	sodium chloride 0.9% flush 10 mL	Every visit	S	Until discont'd	
		10 mL, intravenous, PRN, line care, catheter care, Starting when released, for 10 doses		
	☐	sodium chloride 0.9% infusion 250 mL	Every visit	S	Until discont'd	
		250 mL, intravenous, at 30 mL/hr, PRN, Flush bag, Starting when released, Until Discontinued		
	☐	Discontinue IV	Every visit	S	Until discont'd	
		No details available for preview		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	CBC with platelet and differential	Every visit	S	Until discont'd	
		Once Starting when released, Blood		
	☐	Comprehensive metabolic panel	Every visit	S	Until discont'd	
		Once Starting when released, Blood		
	☐	Protein, urine, random	Every visit	S	Until discont'd	
		Once Starting when released, Urine		
	☐	Creatinine level, urine, random	Every visit	S	Until discont'd	
		Once Starting when released, Urine		
	☐	BK virus by PCR	Every visit	S	Until discont'd	
		Once Starting when released
	Specimen Source: Plasma		
	☐	Cytomegalovirus by PCR	Every visit	S	Until discont'd	
		Once Starting when released
	Specimen Source: Plasma		
	☐	HLA antibody screen - post transplant	Every visit	S	Until discont'd	
		Once Starting when released, Blood
	Collect 2 Red Top (10 ml)     
	
	Donor Specific Antigen(DSA)		

Pre-Medications 	

	
	Interval	Defer Until	Duration	
	☐	acetaminophen (TYLENOL) tablet 650 mg	Every visit	S	Until discont'd	
		650 mg, oral, Starting when released, for 1 dose
	Give 30 minutes prior to tocilizumab infusion.
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	diphenhydrAMINE (BENADRYL) tablet 25 mg	Every visit	S	Until discont'd	
		25 mg, oral, Starting when released, for 1 dose
	Give 30 minutes prior to tocilizumab infusion.		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 40 mg	Every visit	S	Until discont'd	
		40 mg, intravenous, Administer over: 5 Minutes, once, Starting when released
	Give 30 minutes prior to tocilizumab infusion.		

Medications 	

	
	Interval	Defer Until	Duration	
	☐	tocilizumab (ACTEMRA) 8 mg/kg in sodium chloride 0.9% 100 mL IVPB (RESTRICTED)	Day 1 of every 1 month, at least 25 days apart	S	Until discont'd	
		8 mg/kg, intravenous, Administer over: 60 Minutes, once, Starting when released
	DO NOT EXCEED 800 MG PER DOSE.  Administer on Week 4 and every 4 weeks thereafter.
	Do not infuse tocilizumab concomitantly in the same intravenous line with other drugs.
	Protect from light.
	Protect from light.
	This medication is restricted to outpatient use with financial approval or inpatient use for grade 3 or 4 cytokine release syndrome.  Please select indication for treatment: Outpatient setting with financial approval from insurance		

Hypersensitivity 	

	
	Interval	Defer Until	Duration	
	☐	acetaminophen (TYLENOL) tablet 650 mg	PRN	S	Until discont'd	
		650 mg, oral, every 4 hours PRN, headaches, fever, myalgia, Starting when released, Until Discontinued
	Give 325-650 mg for headache, fever, myalgia
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	diphenhydrAMINE (BENADRYL) tablet 25 mg	PRN	S	Until discont'd	
		25 mg, oral, every 6 hours PRN, for allergic reaction symptoms, Starting when released, Until Discontinued		
	☐	diphenhydrAMINE (BENADRYL) injection 50 mg	PRN	S	Until discont'd	
		50 mg, intravenous, once PRN, for anaphylactic reaction, Starting when released, Until Discontinued		
	☐	epINEPHrine (ADRENALIN) injection 1 mg/mL 1 mg	PRN	S	Until discont'd	
		1 mg, intravenous, once PRN, anaphylaxis, for anaphylactic reaction, Starting when released, Until Discontinued		
	☐	promethazine (PHENERGAN) tablet 50 mg	PRN	S	Until discont'd	
		50 mg, oral, every 4 hours PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give 25-50 mg every 4-6 hours for nausea/vomiting		
	☐	sodium chloride 0.9% infusion 250 mL	PRN	S	Until discont'd	
		250 mL, intravenous, once PRN, Hydration, Starting when released, Until Discontinued		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 40 mg	Every visit	S	Until discont'd	
		40 mg, intravenous, Administer over: 5 Minutes, once PRN, chills/infusion reaction, Starting when released, for 1 dose