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Breast Cyclophospamide Docetaxel Doxorubicin (21D1)(576 VER: 02-18-15)

Breast Cyclophospamide Docetaxel Doxorubicin (21D1)(576 VER: 02-18-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 06-03-16 (576 VER: 02-18-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cyclophosphamide/Docetaxel/Doxorubicin
Disease Group: Breast
Disease: Breast Cancer (Adjuvant)

Therapy: doxorubicin 50 mg/m2 IV Day 1,
cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1

Cycle Length: 21 days Course: 6 cycles

Reference(s): Martin M, et al. N Engl J Med 2005;352:2302-13

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Creatinine, Total Bilirubin, AST
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Creatinine > ULN or AST > 1.5 X ULN
or Total Bilirubin > ULN
• Cycle 1, Day 1: Verify patient has obtained pretreatment MUGA or ECHO.
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion
complete for the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for
all subsequent doses if previous doses tolerated.
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV administer 1000 mL throughout chemotherapy

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to DOCEtaxel:
• Cycle 1, Day 1: dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.

Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 24 mg by mouth once. PO preferred – may give 12 mg IV if unable to tolerate PO.
 *aprepitant (Emend) 125 mg by mouth once.
 fosaprepitant (Emend) 150 mg IV once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:

Final Approved VER: 06-03-16 (576 VER: 02-18-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• doxorubicin (Adriamycin) __________mg (50 mg/m2) IV once. Administer as side arm push 3 to 5 mL/minute
into running IV.

• cyclophosphamide (Cytoxan) ____________ mg (500 mg/m2) IV once over 30 minutes. Wait ONE HOUR
after cyclophosphamide to administer DOCEtaxel.

• DOCEtaxel (Taxotere) __________ mg (75 mg/m2) IV once over 60 minutes in non-PVC bag and non-PVC
tubing. Wait ONE HOUR after cyclophosphamide to administer.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. NOTE: Incompatible with dextrose.

Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #36, Refills: 1
Take 2 tablets (8 mg) by mouth 2 times daily for 3 days, starting in the AM on the day prior to DOCEtaxel.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

• ranitidine (Zantac) 150 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (150 mg) by mouth two times daily.

 aprepitant (Emend) 80 mg capsule, Disp. #2, Refills: 5
Take 1 capsule by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

Select One: (May substitute formulary equivalent)
 filgrastim (Neupogen) 300 mcg/0.5 mL syringe. Disp. 10 syringes, Refills: 5
Inject one syringe (300 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose on Day 2 and continue until ANC is greater than ____________ after nadir.

 filgrastim (Neupogen) 480 mcg/0.8 mL syringe. Disp. 10 syringes, Refills: 5
Inject one syringe (480 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose on Day 2 and continue until ANC is greater than ____________ after nadir.

 Other:




Final Approved VER: 06-03-16 (576 VER: 02-18-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 every 21 days

• Labs:
 Other:





• Procedures/Imaging/Scans:
















• Other Orders:










MD Signature_________________________________________ Pager______________
Date __________________Time___________________

Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________