TOFERSEN (QALSODY) INTRATHECAL INJECTION		version 7/7/2023		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☑	Referral to IV Infusion Room	Once	S	1 treatment	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine		

Pre Intrathecal Injection Orders 	

	
	Interval	Defer Until	Duration	
	☐	NPO after midnight	Once	S	1 treatment	
		Except sips with meds.		
	☐	Insert Peripheral IV or Access Portacath	Once	S	1 treatment	
		No details available for preview		
	☐	Nursing communication: Maintain IV access	Once	S	1 treatment	
		No details available for preview		
	☐	Please have patient/family sign consent for Intrathecal Trial	Once	S	1 treatment	
		Procedure: Intrathecal tofersen injection		
	☐	Lumbar puncture tray to bedside	Once	S	1 treatment	
		Normal, Normal		
	☐	Nursing communication: please have the following items available for intrathecal injection:	Once	S	1 treatment	
		Iodine swabs,
	(2) 3 cc sterile syringes,
	7 1/2 and 6 1/2 sterile gloves,
	4x4 gauze,
	Bandaid		
	☐	Consult to PT eval and treat	Once	S	1 treatment	
		Normal
	Special Instructions: Please evaluate patient prior to tofersen injection and post injection.		
	☐	sodium chloride 0.9% flush 10 mL	Once	S	1 treatment	
		10 mL, intravenous, PRN, line care, Starting when released, for 10 doses		

Intrathecal Injections 	

	
	Interval	Defer Until	Duration	
	☐	tofersen (Qalsody) intrathecal injection (RESTRICTED) 100 mg	Every 2 weeks	S	3 treatments	
		100 mg, intrathecal, once, Starting when released
	For intraTHECAL use only.  Prior to administration, remove 10 mL cerebrospinal fluid. Administer tofersen at room temperature. Discard if not given within 4 hours.  Administer over 1 - 3 minutes.
	Use within 4 hours. Do NOT shake or tube. Protect from light. Do NOT infuse/inject concomitantly with other agents.		
	☐	tofersen (Qalsody) intrathecal injection (RESTRICTED) 100 mg	Every 4 weeks	S+28	Until discont'd	
		100 mg, intrathecal, once, Starting when released
	Administer every 28 days following the third loading dose.  For intraTHECAL use only.  Prior to administration, remove 10 mL cerebrospinal fluid. Administer tofersen at room temperature. Discard if not given within 4 hours.  Administer over 1 - 3 minutes.
	Use within 4 hours. Do NOT shake or tube. Protect from light. Do NOT infuse/inject concomitantly with other agents.		

Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☐	Discontinue IV	Once	S	1 treatment	
		Until discontinued Starting when released Until Specified		
	☐	HEParin, porcine injection 500 Units	Once	S	1 treatment	
		500 Units, intra-catheter, once, Starting when released
	ONLY IF PATIENT HAS PORTACATH: Flush portacath before removing needle from portacath.		

Post Intrathecal Injection Orders 	

	
	Interval	Defer Until	Duration	
	☐	Nursing communication	Once	S	1 treatment	
		Continue all active admission orders including pulse ox.
	Flat in bed until ***.
	Regular diet after ***.
	Pt to take home medications.
	Discharge patient home after last PT visit.		
	☐	acetaminophen (TYLENOL) tablet 650 mg	Once	S	1 treatment	
		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	Once	S	1 treatment	
		25 mg, oral, every 6 hours PRN, itching, Starting when released, Until Discontinued		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Once	S	1 treatment	
		25 mg, intravenous, every 6 hours PRN, itching, Starting when released, Until Discontinued		
	☐	ondansetron (ZOFRAN) injection 4 mg	Once	S	1 treatment	
		4 mg, intravenous, every 4 hours PRN, nausea, vomiting, Starting when released, Until Discontinued
	May cause QTc prolongation.		
	☐	ondansetron (ZOFRAN) tablet 8 mg	PRN	S	1 treatment	
		8 mg, oral, every 4 hours PRN, nausea, vomiting, Starting when released, Until Discontinued
	May cause QTc prolongation.		
	☐	promethazine (PHENERGAN) tablet 25 mg	Once	S	1 treatment	
		25 mg, oral, every 6 hours PRN, nausea, vomiting, Starting when released, Until Discontinued		
	☐	promethazine (PHENERGAN) injection 25 mg	Once	S	1 treatment	
		25 mg, intravenous, every 6 hours PRN, nausea, vomiting, Starting when released, Until Discontinued		
	☐	sodium chloride 0.9% infusion 250 mL	Once	S	1 treatment	
		250 mL, intravenous, at 30 mL/hr, once, Starting when released
	TKO during recovery