CAGT - NON-FORMULARY ECULIZUMAB (SOLIRIS) FOR PNH		version 8/26/2026		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☑	Referral to IV Infusion Room Appointment requests for induction doses.	1 time a week	S	4 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment requests for induction doses.		
	☑	Referral to IV Infusion Room Appointment requests for maintenance doses.	Every 2 weeks	S+28	 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment requests for maintenance doses.		

Provider Communication 	

	
	Interval	Defer Until	Duration	
	☐	Provider communication	Every visit	S	Until discont'd	
		Verify the patient received the meningococcal vaccines serogroups A, C, W, Y, and B 2 weeks prior to starting treatment. If not, please order the vaccine for administration, and start prophylaxis antibiotics (penicillin VK 500 mg twice daily or ciprofloxacin 500 mg twice daily) until 2 weeks after completion of vaccination series.		
	☐	Provider communication	Every visit	S	 treatments	
		Meningococcal Group B vaccine is administered at 0, 1-2, and 6 months. A booster dose 1 year after completion of primary series and every 2-3 years thereafter for the duration of complement inhibitor therapy is recommended.
	Meningococcal ACWY vaccine requires a 2-4-dose primary series depending on the brand and age. A booster dose of MenACWY vaccine is recommended every 5 years, for the duration of complement inhibitor therapy.		

Immunizations 	

	
	Interval	Defer Until	Duration	
	☐	Meningococcal Group B vaccine (BEXSERO)	Once	S	1 treatment	
		0.5 mL, intramuscular, once, Starting when released
	1 dose on therapy start date. 
	 
	Administer BEXSERO as a 0.5 mL intramuscular injection into the deltoid muscle of the upper arm.
	Shake the syringe immediately before use to form a homogeneous suspension.		
	☐	mening vac A,C,Y,W135 dip (PF) (MENVEO) IM injection 0.5 mL	Once	S	1 treatment	
		0.5 mL, intramuscular, once, Starting when released
	1 dose on therapy start date		

2 Month Immunization 	

	
	Interval	Defer Until	Duration	
	☐	Meningococcal Group B vaccine (BEXSERO)	Once	S+60	1 treatment	
		0.5 mL, intramuscular, once, Starting when released
	1 dose 2 month after therapy start date.
	
	Give as a 2-dose series for adolescents and young adults not at increased risk and as a 3-dose series for individuals at increased risk.
	Shake the syringe immediately before use to form a homogeneous suspension.		
	☐	mening vac A,C,Y,W135 dip (PF) (MENVEO) IM injection 0.5 mL	Once	S+60	1 treatment	
		0.5 mL, intramuscular, once, Starting when released
	1 dose 2 month after therapy start date.		

6 Month Immunization 	

	
	Interval	Defer Until	Duration	
	☐	Meningococcal Group B vaccine (BEXSERO)	Once	S+180	1 treatment	
		0.5 mL, intramuscular, once, Starting when released
	1 dose 6 month after therapy start date.
	
	Give as a 2-dose series for adolescents and young adults not at increased risk and as a 3-dose series for individuals at increased risk.
	Shake the syringe immediately before use to form a homogeneous suspension.		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	CBC with Platelet and Differential	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect, HMH DEPARTMENT OF PATHOLOGY AND GENOMIC MEDICINE		
	☐	Comprehensive metabolic panel	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect, HMH DEPARTMENT OF PATHOLOGY AND GENOMIC MEDICINE		

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		
	☐	Discontinue IV	Every visit	S	Until discont'd	
		No details available for preview		

Medications 	

	
	Interval	Defer Until	Duration	
	☐	eculizumab (SOLIRIS) infusion (RESTRICTED) 600 mg	1 time a week	S	4 treatments	
		600 mg, intravenous, once, Starting when released
	Induction: 600 mg weekly for 4 doses.		
	☐	eculizumab (SOLIRIS) infusion (RESTRICTED) 900 mg	Every 2 weeks	S+28	 treatments	
		900 mg, intravenous, once, Starting when released
	Maintenance: 900 mg at week 5, then 900 mg every 2 weeks.		

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