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201706166

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CSC GU Doxorubicin(14D:1) Gemcitabine(14D:1) VER 12-1-16 (HL 841)

CSC GU Doxorubicin(14D:1) Gemcitabine(14D:1) VER 12-1-16 (HL 841) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU DOXORUBICIN(14D:1)/GEMCITABINE(14D:1) VER: 12-1-16 (HL 841) – Properties
Pre-Cycle – 6/8/2017 through 6/14/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting (For nausea)., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS
PRN starting S
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 – 6/15/2017 through 6/28/2017 (14 days), Planned
Day 1, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Reference Information (1)
BLADDER/URACHAL/UROTHELIAL CANCER/RENAL CELL CARCINOMA/SARCOMATOID: Nanus DM, et al. Cancer 2004;101
(7):1545-51.
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 1 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
gemcitabine (GEMZAR) 2,940 mg in sodium chloride 0.9 % 100 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine, Total Bilirubin, ALT,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and gemcitabine for 120 minutes.
Lab Only - Day 8, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 2 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/29/2017 through 7/12/2017 (14 days), Planned
Day 1, Cycle 2 – Planned for 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 3 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
gemcitabine (GEMZAR) 2,940 mg in sodium chloride 0.9 % 100 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine, Total Bilirubin, ALT,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and gemcitabine for 120 minutes.
Lab Only - Day 8, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/13/2017 through 7/26/2017 (14 days), Planned
Day 1, Cycle 3 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 4 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
gemcitabine (GEMZAR) 2,940 mg in sodium chloride 0.9 % 100 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine, Total Bilirubin, ALT,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and gemcitabine for 120 minutes.
Lab Only - Day 8, Cycle 3 – Planned for 7/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 5 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 7/27/2017 through 8/9/2017 (14 days), Planned
Day 1, Cycle 4 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Hydration
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 6 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
gemcitabine (GEMZAR) 2,940 mg in sodium chloride 0.9 % 100 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine, Total Bilirubin, ALT,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and gemcitabine for 120 minutes.
Lab Only - Day 8, Cycle 4 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 8/10/2017 through 8/23/2017 (14 days), Planned
Day 1, Cycle 5 – Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 7 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
gemcitabine (GEMZAR) 2,940 mg in sodium chloride 0.9 % 100 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine, Total Bilirubin, ALT,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and gemcitabine for 120 minutes.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 8 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Lab Only - Day 8, Cycle 5 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 8/24/2017 through 9/6/2017 (14 days), Planned
Day 1, Cycle 6 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 9 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
gemcitabine (GEMZAR) 2,940 mg in sodium chloride 0.9 % 100 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine, Total Bilirubin, ALT,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and gemcitabine for 120 minutes.
Lab Only - Day 8, Cycle 6 – Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Genitourinary Malignancy (Advanced) - Sarcomatoid Histology; THERAPY: doxorubicin 50 mg/m2 IV Day 1, gemcitabine
1500 mg/m2 IV Day 1; CYCLE LENGTH: 14 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:54:28 AM Page 10 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org