UPLIZNA THERAPY PLAN		version 6/17/2025		

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
	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
	Urgency of Scheduling: Routine
	Appointment request for second dose.		
	☑	Referral to IV Infusion Room Appointment request for subsequent doses.	Every 180 days	S+180	 treatments	
		Status: Future, Expected: S, Expires: S+365
	Urgency of Scheduling: Routine
	Appointment request for subsequent doses.		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	Immunoglobulin G	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Immunoglobulin M	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Immunoglobulin A	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Hepatitis B surface antigen	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect		
	☐	Hepatitis B core antibody total	Every visit	S	Until discont'd	
		Routine, Normal, Clinic Collect		

Provider Communication 	

	
	Interval	Defer Until	Duration	
	☑	Nursing communication	Every visit	S	Until discont'd	
		Administer all vaccines at least 4 weeks prior to initiation of inebilizumab		
	☑	Nursing communication	Every visit	S	Until discont'd	
		Screen for tuberculosis (TB) disease (active TB) prior to inebilizumab initiation. Screening date***		
	☑	Verify Hepatitis B Panel Status	Every visit	S	Until discont'd	
		Verify Hep B panel status prior to cycle. Date *** of panel. Result {positive/negative/pending/unknown:22867}
	
	The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).		

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		
	☐	sodium chloride 0.9% flush 10 mL	Every visit	S	Until discont'd	
		10 mL, intravenous, PRN, line 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		
	☐	HEParin, porcine injection 500 Units	Every visit	S	Until discont'd	
		500 Units, intra-catheter, once PRN, line care, Starting when released, Until Discontinued
	Heparin flush for Implanted Vascular Access Device Maintenance.		
	☐	Discontinue IV	Every visit	S	Until discont'd	
		No details available for preview		

Pre-Medications 	

	
	Interval	Defer Until	Duration	
	☐	acetaminophen (TYLENOL) tablet 650 mg	Every visit	S	Until discont'd	
		650 mg, oral, once, Starting when released
	30 to 60 minutes prior to 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, once, Starting when released
	30 to 60 minutes prior to infusion		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 100 mg	Every visit	S	Until discont'd	
		100 mg, intravenous, once, Starting when released
	30 to 60 minutes prior to infusion		

Medications 	

	
	Interval	Defer Until	Duration	
	☐	inebilizumab-cdon (UPLIZNA) 300 mg in sodium chloride 0.9% 250 mL	Once	S	1 treatment	
		300 mg, intravenous, at 42 mL/hr, once, Starting when released
	Administer by IV Infusion pump and using a low-protein binding 0.2 or 0.22 micron in-line filter.
	Allow medication to reach room temperature prior to administration.
	Administer diluted infusion over approximately 90 minutes at an increasing rate: 42 mL/hour for first 30 minutes, followed by 125 mL/hour for the next 30 minutes, then 333 mL/hour until completion.		
	☐	inebilizumab-cdon (UPLIZNA) 300 mg in sodium chloride 0.9% 250 mL	Once	S+14	1 treatment	
		300 mg, intravenous, at 42 mL/hr, once, Starting when released
	Administer by IV Infusion pump and using a low-protein binding 0.2 or 0.22 micron in-line filter.
	Allow medication to reach room temperature prior to administration. 
	Administer diluted infusion over approximately 90 minutes at an increasing rate: 42 mL/hour for first 30 minutes, followed by 125 mL/hour for the next 30 minutes, then 333 mL/hour until completion.		
	☐	inebilizumab-cdon (UPLIZNA) 300 mg in sodium chloride 0.9% 250 mL	Every 180 days	S+180	Until discont'd	
		300 mg, intravenous, at 42 mL/hr, once, Starting when released
	Administer by IV Infusion pump and using a low-protein binding 0.2 or 0.22 micron in-line filter.
	Allow medication to reach room temperature prior to administration. 
	Administer diluted infusion over approximately 90 minutes at an increasing rate: 42 mL/hour for first 30 minutes, followed by 125 mL/hour for the next 30 minutes, then 333 mL/hour until completion.		

Hypersensitivity 	

	
	Interval	Defer Until	Duration	
	☐	acetaminophen (TYLENOL) tablet 650 mg	PRN	S	Until discont'd	
		650 mg, oral, every 4 hours PRN, mild pain (score 1-3), Starting when released, Until Discontinued
	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, itching, Starting when released, Until Discontinued		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	PRN	S	Until discont'd	
		25 mg, intravenous, once PRN, for minor infusion reaction, Starting when released, Until Discontinued		
	☐	diphenhydrAMINE (BENADRYL) injection 50 mg	PRN	S	Until discont'd	
		50 mg, intravenous, once PRN, for severe infusion reaction, Starting when released, Until Discontinued		
	☐	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.5 mg	PRN	S	Until discont'd	
		0.5 mL, subcutaneous, once PRN, anaphylaxis, Starting when released, Until Discontinued		
	☐	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	PRN	S	Until discont'd	
		100 mg, intravenous, once PRN, for infusion reaction, Starting when released, Until Discontinued		
	☐	promethazine (PHENERGAN) tablet 25 mg	PRN	S	Until discont'd	
		25 mg, oral, every 6 hours PRN, nausea, vomiting, Starting when released, Until Discontinued		
	☐	sodium chloride 0.9% infusion 250 mL	PRN	S	Until discont'd	
		250 mL, intravenous, once PRN, Hydration, Starting when released, Until Discontinued