CERTOLIZUMAB PEGOL (CIMZIA) INJECTION 400 MG		version 2/27/2025		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☑	Referral to IV Infusion Room Appointment requests for initial doses.	Every 2 weeks	S	3 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment requests for initial doses.		
	☑	Referral to IV Infusion Room Appointment requests for subsequent doses.	Every 4 weeks	S+55	 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment requests for subsequent doses.		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	CBC with platelet and differential	Every visit	S	Until discont'd	
		Normal, Clinic Collect
	Labs to be drawn at Physicians office unless otherwise noted: for first 3 visits on new starts then every 4 months.		
	☐	Comprehensive metabolic panel	Every visit	S	Until discont'd	
		Normal, Clinic Collect
	Labs to be drawn at Physicians office unless otherwise noted: for first 3 visits on new starts then every 4 months.		
	☐	Sedimentation rate	Every visit	S	Until discont'd	
		Normal, Clinic Collect
	Labs to be drawn at Physicians office unless otherwise noted: for first 3 visits on new starts then every 4 months.		
	☐	C-reactive protein	Every visit	S	Until discont'd	
		Normal, Clinic Collect
	Labs to be drawn at Physicians office unless otherwise noted: for first 3 visits on new starts then every 4 months.		

Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☐	Vital signs - T/P/R/BP Per Unit Protocol	Every visit	S	Until discont'd	
		Obtain vitals prior to injection and then every 15 minutes for 30 minutes.  Instruct patient to report symptoms of chills, fever, or pain.		

Medications 	

	
	Interval	Defer Until	Duration	
	☐	certolizumab pegoL (CIMZIA) 400 mg/2 mL (200 mg/mL x 2) subcutaneous injection 400 mg	Every 2 weeks	S	3 treatments	
		400 mg, subcutaneous, once, Starting when released
	Administer on Weeks 0, 2, and 4.
	Administer subcutaneously (using provided 23-gauge needle) into the thigh or abdomen (avoiding areas within 2 inches of navel)		
	☐	certolizumab pegoL (CIMZIA) 400 mg/2 mL (200 mg/mL x 2) subcutaneous injection 400 mg	Every 4 weeks	S+55	Until discont'd	
		400 mg, subcutaneous, once, Starting when released
	Administer on Week 8 then every 4 weeks thereafter.
	Administer subcutaneously (using provided 23-gauge needle) into the thigh or abdomen (avoiding areas within 2 inches of navel)		

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