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GI Fluorouracil(28D:1,15)/Irinotecan(28D:1,15)/Leucovorin(28D:1,15)/Oxaliplatin(28D:1,15) (3589 VER: 04-19-13)

GI Fluorouracil(28D:1,15)/Irinotecan(28D:1,15)/Leucovorin(28D:1,15)/Oxaliplatin(28D:1,15) (3589 VER: 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 01-27-16 (3589 VER: 04-19-13) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Fluorouracil/Irinotecan/Leucovorin/Oxaliplatin (FOLFIRINOX)
Disease Group: Gastrointestinal
Disease: Pancreatic Cancer (Advanced)

Therapy: oxaliplatin 85 mg/m2 IV Day 1 and 15,
leucovorin 400 mg/m2 IV Day 1 and 15,
irinotecan 180 mg/m2 IV Day 1 and 15,
fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours
(Total dose = 2400 mg/m2 IV over 46 hours per home infusion) on Day 1 and 15

Cycle Length: 28 days Course: indefinite or until disease progression or toxicity

Reference(s): Conroy T, et al. J Clin Oncol. 2010;28(15_suppl): Abstract 4010.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 15 (date) ___________

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


• Day 15: Obtain CBC without DIFF, ANC, Creatinine, Total Bilirubin
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase
 Day 15: Verify the following labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin
• Hold and notify provider for:
 Day 1: ANC < 1000/µL or Platelets < 75K/µL or Creatinine ≥ 1.5 mg/dL or
Creatinine Clearance < 30 mL/min or Total Bilirubin > 1.5 times ULN or
AST > 3 times ULN or ALT > 3 times ULN or Alkaline Phosphatase ≥ 3 times ULN
(no liver metastases present) or ≥ 5 times ULN (liver metastases present)
 Day 15: ANC < 1000/µL or Platelets < 75K/µL or Creatinine ≥ 1.5 mg/dL or
Creatinine clearance < 30 mL/min or Total Bilirubin > 1.5 times ULN

Nursing Procedure, Assessment and Monitoring:
• Check for mucositis, irritation of hands or feet, or diarrhea.
• Monitor patient during irinotecan infusion for cholinergic syndrome and early/late onset diarrhea.
• Educate/reinforce with patient oxaliplatin neuropathy exacerbated by cold.
• Flush/Line Care per Institution standards
• Disconnect pump upon completion of 46-hour fluorouracil infusion on Day 3 and 17:
 In Clinic  At Home By Patient  At Home by Home Health Nurse  Other _______________

Final Approved VER: 01-27-16 (3589 VER: 04-19-13) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Hydration/Fluids: Dextrose 5% in Water IV to establish line and for flushing

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *dexamethasone (Decadron) 12 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 *fosaprepitant (Emend) 150 mg IV once.
 *palonosetron (Aloxi) 0.25 mg IV once.
 Other:

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:



• oxaliplatin (Eloxatin) __________ mg (85 mg/m2) IV once over 120 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. NOTE: Incompatible with sodium chloride.

• leucovorin __________ mg (400 mg/m2) IV once over 120 minutes. Start infusion during last 30 minutes of
oxaliplatin administration.

• irinotecan (Camptosar) __________ mg (180 mg/m2) IV once over 90 minutes concurrently with remaining 90
minutes of leucovorin.

• fluorouracil (Adrucil) __________ mg (400 mg/m2) IV bolus once over 5 minutes.

• fluorouracil (Adrucil) __________ mg (2400 mg/m2) continuous IV infusion once over 46 hours.

Treatment Medications for Day 15: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• oxaliplatin (Eloxatin) __________ mg (85 mg/m2) IV once over 120 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. NOTE: Incompatible with sodium chloride.

• leucovorin __________ mg (400 mg/m2) IV once over 120 minutes. Start infusion during last 30 minutes of
oxaliplatin administration.

• irinotecan (Camptosar) __________ mg (180 mg/m2) IV once over 90 minutes concurrently with remaining 90
minutes of leucovorin.

• fluorouracil (Adrucil) __________ mg (400 mg/m2) IV bolus once over 5 minutes.

• fluorouracil (Adrucil) __________ mg (2400 mg/m2) continuous IV infusion once over 46 hours.


Final Approved VER: 01-27-16 (3589 VER: 04-19-13) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Conditional Orders Day 1 and 15:
• atropine 0.3 mg subcutaneous PRN for irinotecan cholinergic side effects. May repeat every 30 minutes PRN
for a total of 3 doses. Total allowed dose = 0.9 mg.

Other Orders for Day 1 and/or 15:





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 once daily for 3 days following start of fluorouracil infusion.

• 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.

• loperamide (Imodium) 2 mg tablet, Disp. Available OTC
Take 2 tablets (4 mg) by mouth with 1
st
loose stool followed by 1 tablet every 2 hours or 2 tablets every 4
hours until no diarrhea for 12 hours. Max dose = 8 tablets/day.

Select One: (May substitute formulary equivalent)
 filgrastim (Neupogen) 300 mcg/0.5 mL syringe. Disp. 10 syringes, Refills: 6
Inject one syringe (300 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose on Day 4 through 8 and Day 18 through 22.

 filgrastim (Neupogen) 480 mcg/0.8 mL syringe. Disp. 10 syringes, Refills: 6
Inject one syringe (480 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose on Day 4 through 8 and Day 18 through 22.

 Other:















Final Approved VER: 01-27-16 (3589 VER: 04-19-13) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 and 15 every 28 days





• Procedures/Imaging/Scans:












• Other Orders:













MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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