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Samaritan Hospital – Troy - Albany Memorial Campus-

St. Mary’s Campus

Casirivimab/Imdevimab Subcutaneous Injection Order Form Please check each order box that you want initiated. Orders not checked will not be implemented.

Any Additions, Deletions, or Strike-Outs Require a Practitioner's Initials. Allergies:

**Prior to administration, the patient/caregiver must be given the patient fact sheet and provided information

consistent with the following: Casirivimab and imdevimab use is authorized by the FDA for emergency use but

is not an FDA approved drug, the potential risks and benefits of casirivimab and imdevimab the extent to

which such risks and benefits are unknown, and available alternative treatments**

ORDERS

Patient/caregiver received "Fact Sheet for Patients, Parents and Caregivers Emergency Use

Authorization (EUA) of casirivimab and imdevimab for Coronavirus Disease 2019 (COVID-19)"

For Adults and Pediatric Patients at least 12 years old and Weighing >/= 40 KG

Casirivimab 600 mg/imdevimab 600 mg subcutaneously. Inject four casirivimab-imdevimab 60mg-60

mg/ml 2.5ml syringes into thigh, back of the upper arm or abdomen, except for 2 inches around naval.

Avoid waistline. DO NOT inject into skin that is tender, damaged, bruised of scarred.

Check vitals X 2 (right before drug administration and 1 hour post administration).

***Patient MUST be observed for 1 hour post subcutaneous administration for signs and

symptoms of allergic reaction***

Acetaminophen (Tylenol) 650 mg PO times 1 dose for fever greater than 100.5

Ibuprofen 600 mg PO times 1 dose, if unable to take acetaminophen

Ondansetron (Zofran) 4 mg IVP times 1 dose for nausea

Two liters via nasal canula for SAT less than 90% and respiratory distress as needed. Titrate O2 if SAT

fails to raise above 94%. Notify provider.

In the event of anaphylactic reaction such as dyspnea, rash, hives or swelling, administer and notify provider

Diphenhydramine (Benadryl) 25 mg IVP times 1 dose (for hives)

Diphenhydramine (Benadryl) 50 mg IVP times 1 dose (for anaphylaxis)

Famotidine (Pepcid) 20 mg IVP x1 dose

Epinephrine 0.3 mg IM every 5 minutes as needed for anaphylaxis reaction. Max of 3 doses.

Hydrocortisone 100 mg IV times 1 dose

Apply O2 to maintain O2 sat greater the 90%

0.9% sodium chloride IV bolus 1000ml, infuse over 30 minutes x1 dose

Physician's Signature _________________________________________ Date ___________________ Time __________________

Physician Name (Please PRINT CLEARLY): ___________________________________________________

FAX COMPLETED FORM TO 518-525-6790

Patient Name: Patient DOB: