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IP/OP BIWEEKLY TALQUETAMAB-TGVS (TALVEY)	

Types:      ONCOLOGY TREATMENT
Synonyms:  

Cycle 1 (IP Observation Status for Step-Up Dosing)	Repeat 1 time	Cycle length: 24 days	Day 1	Perform every 1 day x1		Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and NOTIFY provider if:
-  ANC LESS than 1,000
-  Platelets LESS than 100,000
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist.
			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Due to risk of cytokine release syndrome (CRS) and neurologic toxicity, patients should be hospitalized for 48 hours after administration of talquetamab-tgvs step-up doses including the first treatment dose.
		  	ONC NURSING COMMUNICATION 2	Interval: Until discontinued	Occurrences: --	Comments:	Please document patient's ICE score in the flowsheet 30 minutes after completion of injection.
		  	ONC NURSING COMMUNICATION 11	Interval: Until discontinued	Occurrences: --	Comments:	Oxygen at bedside during step up doses and until discharged. Anaphylaxis precautions at bedside during step up doses and until discharged.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Obtain baseline vital signs (T, P, R, BP, Oxygen saturation +/- breath sounds).
		  	PULSE OXIMETRY	Interval: Continuous	Occurrences: --	Comments:	Continuous pulse oximetry monitoring during injection and for 30 minutes post injection.
		  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Confirm drug and dosage form prior to administration.
			Labs
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Obtain baseline labs.
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		  	HEPATITIS B SURFACE ANTIGEN	Interval: Once	Occurrences: --		  	HEPATITIS B SURFACE ANTIBODY	Interval: Once	Occurrences: --		  	HEPATITIS B CORE ANTIBODY TOTAL	Interval: Once	Occurrences: --			Labs
  	SERUM ELECTROPHORESIS	Interval: Once	Occurrences: --		  	KAPPA LAMBDA FREE LIGHT CHAIN WITH RATIO	Interval: Once	Occurrences: --			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	dexAMETHasone (DECADRON) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.			Chemotherapy
  	talquetamab-tgvs (TALVEY) subcutaneous injection (RESTRICTED) 0.01 mg/kg (Treatment Plan)	Dose: 0.01 mg/kg	Route: subcutaneous	once for 1 dose			Offset: 60 Minutes	Instructions:	Doses requiring GREATER than 2 ml total volume should be equally divided into multiple syringes. Ensure Talquetamab and emergency equipment are available prior to injection and set aside for this patient.
Inject into the subcutaneous tissue of the abdomen (preferred) or thigh. 
Do not inject into tattoos or scars or areas where the skin is red, bruised, tender, hard or not intact. 
HAZARDOUS - Handle with care 
Do not tube or shake		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Vital signs (T, P, R, BP, +/- breath sounds) at completion of injection, then at 30 minutes post and 60 minutes post injection.
			Emergency Medications
  	meperidine (DEMEROL) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	If rigors persist, contact MD.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Day 4	Perform every 1 day x1		Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and NOTIFY provider if:
-  ANC LESS than 1,000
-  Platelets LESS than 100,000
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist.
			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Due to risk of cytokine release syndrome (CRS) and neurologic toxicity, patients should be hospitalized for 48 hours after administration of talquetamab-tgvs step-up doses including the first treatment dose.
		  	ONC NURSING COMMUNICATION 2	Interval: Until discontinued	Occurrences: --	Comments:	Please document patient's ICE score in the flowsheet 30 minutes after completion of injection.
		  	ONC NURSING COMMUNICATION 11	Interval: Until discontinued	Occurrences: --	Comments:	Oxygen at bedside during step up doses and until discharged. Anaphylaxis precautions at bedside during step up doses and until discharged.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Obtain baseline vital signs (T, P, R, BP, Oxygen saturation +/- breath sounds).
		  	PULSE OXIMETRY	Interval: Continuous	Occurrences: --	Comments:	Continuous pulse oximetry monitoring during injection and for 30 minutes post injection.
		  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Confirm drug and dosage form prior to administration.
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	dexAMETHasone (DECADRON) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.			Chemotherapy
  	talquetamab-tgvs (TALVEY) subcutaneous injection (RESTRICTED) 0.06 mg/kg (Treatment Plan)	Dose: 0.06 mg/kg	Route: subcutaneous	once for 1 dose			Offset: 60 Minutes	Instructions:	Doses requiring GREATER than 2 ml total volume should be equally divided into multiple syringes. Ensure Talquetamab and emergency equipment are available prior to injection and set aside for this patient.
Inject into the subcutaneous tissue of the abdomen (preferred) or thigh. 
Do not inject into tattoos or scars or areas where the skin is red, bruised, tender, hard or not intact. 
HAZARDOUS - Handle with care 
Do not tube or shake		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Vital signs (T, P, R, BP, +/- breath sounds) at completion of injection, then at 30 minutes post and 60 minutes post injection.
			Emergency Medications
  	meperidine (DEMEROL) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	If rigors persist, contact MD.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Day 7	Perform every 1 day x1		Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and NOTIFY provider if:
-  ANC LESS than 1,000
-  Platelets LESS than 100,000
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist.
			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Due to risk of cytokine release syndrome (CRS) and neurologic toxicity, patients should be hospitalized for 48 hours after administration of talquetamab-tgvs step-up doses including the first treatment dose.
		  	ONC NURSING COMMUNICATION 2	Interval: Until discontinued	Occurrences: --	Comments:	Please document patient's ICE score in the flowsheet 30 minutes after completion of injection.
		  	ONC NURSING COMMUNICATION 11	Interval: Until discontinued	Occurrences: --	Comments:	Oxygen at bedside during step up doses and until discharged. Anaphylaxis precautions at bedside during step up doses and until discharged.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Obtain baseline vital signs (T, P, R, BP, Oxygen saturation +/- breath sounds).
		  	PULSE OXIMETRY	Interval: Continuous	Occurrences: --	Comments:	Continuous pulse oximetry monitoring during injection and for 30 minutes post injection.
		  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Confirm drug and dosage form prior to administration.
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	dexAMETHasone (DECADRON) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.			Chemotherapy
  	talquetamab-tgvs (TALVEY) subcutaneous injection (RESTRICTED) 0.4 mg/kg (Treatment Plan)	Dose: 0.4 mg/kg	Route: subcutaneous	once for 1 dose			Offset: 60 Minutes	Instructions:	Doses requiring GREATER than 2 ml total volume should be equally divided into multiple syringes. Ensure Talquetamab and emergency equipment are available prior to injection and set aside for this patient.
Inject into the subcutaneous tissue of the abdomen (preferred) or thigh. 
Do not inject into tattoos or scars or areas where the skin is red, bruised, tender, hard or not intact. 
HAZARDOUS - Handle with care 
Do not tube or shake		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Vital signs (T, P, R, BP, +/- breath sounds) at completion of injection, then at 30 minutes post and 60 minutes post injection.
			Emergency Medications
  	meperidine (DEMEROL) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	If rigors persist, contact MD.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Day 10	Perform every 1 day x1		Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and NOTIFY provider if:
-  ANC LESS than 1,000
-  Platelets LESS than 100,000
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist.
			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Due to risk of cytokine release syndrome (CRS) and neurologic toxicity, patients should be hospitalized for 48 hours after administration of talquetamab-tgvs step-up doses including the first treatment dose.
		  	ONC NURSING COMMUNICATION 2	Interval: Until discontinued	Occurrences: --	Comments:	Please document patient's ICE score in the flowsheet 30 minutes after completion of injection.
		  	ONC NURSING COMMUNICATION 11	Interval: Until discontinued	Occurrences: --	Comments:	Oxygen at bedside during step up doses and until discharged. Anaphylaxis precautions at bedside during step up doses and until discharged.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Obtain baseline vital signs (T, P, R, BP, Oxygen saturation +/- breath sounds).
		  	PULSE OXIMETRY	Interval: Continuous	Occurrences: --	Comments:	Continuous pulse oximetry monitoring during injection and for 30 minutes post injection.
		  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Confirm drug and dosage form prior to administration.
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.		  	dexAMETHasone (DECADRON) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes prior to talquetamab.			Chemotherapy
  	talquetamab-tgvs (TALVEY) subcutaneous injection (RESTRICTED) 0.8 mg/kg (Treatment Plan)	Dose: 0.8 mg/kg	Route: subcutaneous	once for 1 dose			Offset: 60 Minutes	Instructions:	Doses requiring GREATER than 2 ml total volume should be equally divided into multiple syringes. Ensure Talquetamab and emergency equipment are available prior to injection and set aside for this patient.
Inject into the subcutaneous tissue of the abdomen (preferred) or thigh. 
Do not inject into tattoos or scars or areas where the skin is red, bruised, tender, hard or not intact. 
HAZARDOUS - Handle with care 
Do not tube or shake		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Vital signs (T, P, R, BP, +/- breath sounds) at completion of injection, then at 30 minutes post and 60 minutes post injection.
			Emergency Medications
  	meperidine (DEMEROL) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	If rigors persist, contact MD.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S							
Cycles 2 to 6	Repeat 5 times	Cycle length: 14 days	Day 1	Perform every 1 day x1		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 3	Interval: --	Occurrences: --			Treatment Conditions
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and NOTIFY provider if:
-  ANC LESS than 1,000
-  Platelets LESS than 100,000
		  	TREATMENT CONDITIONS 11	Interval: --	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	Please hold and contact provider if previous talquetamab-tgvs dose administered GREATER than 28 days as this may warrant restarting step-up dosing schedule.
			Nursing Orders
  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Please document patient's ICE score in the flowsheet 30 minutes after completion of injection.
		  	ONC NURSING COMMUNICATION 12	Interval: --	Occurrences: --	Comments:	Confirm patient has received 4 step-up doses prior to first maintenance injection of 0.8mg/kg.
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Obtain baseline vital signs (T, P, R, BP, Oxygen saturation +/- breath sounds).
		  	ONC NURSING COMMUNICATION 10	Interval: --	Occurrences: --	Comments:	Confirm drug and dosage form prior to administration.
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	SERUM ELECTROPHORESIS	Interval: Once	Occurrences: --		  	KAPPA LAMBDA FREE LIGHT CHAIN WITH RATIO	Interval: Once	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	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.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	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.
			Chemotherapy
  	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	Premedication may be necessary prior to subsequent doses in patients who repeat doses within the talquetamab-tgvs step-up dosing schedule (following a dose delay), or who experienced CRS following the prior talquetamab-tgvs dose.
		  	talquetamab-tgvs (TALVEY) subcutaneous injection (RESTRICTED) 0.8 mg/kg (Treatment Plan)	Dose: 0.8 mg/kg	Route: subcutaneous	once for 1 dose	Start: S			Instructions:	Doses requiring GREATER than 2 ml total volume should be equally divided into multiple syringes. Ensure Talquetamab and emergency equipment are available prior to injection and set aside for this patient.
Inject into the subcutaneous tissue of the abdomen (preferred) or thigh. 
Do not inject into tattoos or scars or areas where the skin is red, bruised, tender, hard or not intact. 
HAZARDOUS - Handle with care 
Do not tube or shake			Emergency Medications
  	meperidine (DEMEROL) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	If rigors persist, contact MD.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled			Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.