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GYN Carboplatin 21D1 (520 VER: 3-4-13)

GYN Carboplatin 21D1 (520 VER: 3-4-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 07-11-16 (520 VER: 3-4-13) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carboplatin
Disease Group: Gynecology/Oncology
Disease: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced)

Therapy: CARBOplatin AUC = 4 to 6 IV Day 1

Cycle Length: 21 days Course: 6 cycles

Reference(s): The International Collaborative Ovarian Neoplasm (ICON) Group. Lancet 2002;360:505-15.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC without DIFF, ANC, Potassium, CA 125, Magnesium, Creatinine
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Hold and notify provider for: ANC ≤ 1500/µL or Platelets ≤ 100K/µL or Creatinine > ULN


Nursing Procedure, Assessment and Monitoring: Flush/Line Care per Institution standards


Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing


Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:



Final Approved VER: 07-11-16 (520 VER: 3-4-13) 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:



• CARBOplatin (Paraplatin) __________ mg (Dosed AUC = ______) IV once over 60 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

(GFR + 25) X AUC = Carboplatin dose (mg).

NOTE: The GFR used in this equation should not exceed 125 mL/min

Calculated Creatinine Clearance =

(140 – ___Patient age) x (patient weight in _____kg) = ________
72 x serum creatinine

(for females, multiply this result by 0.85) = ________

This value will substitute for GFR to determine Carboplatin dose

(GFR + 25) X AUC = Carboplatin dose (mg)

(_____ + 25) X ____ = Carboplatin _____________mg

Other Orders for Day 1:






Final Approved VER: 07-11-16 (520 VER: 3-4-13) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth twice daily for 2 days and every 8 hours as needed for nausea/vomiting.

 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)

 Other:



Follow Up
• Chemotherapy: Day 1 every 21 days

• Labs:
 Day 10 – Obtain CBC, ANC (DIFF if done locally)
 Other:



• Procedures/Imaging/Scans:












• Other Orders:








MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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