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Breast Cyclophosphamide (21D1) Docetaxel (21D1) (575 VER 02-18-15)

Breast Cyclophosphamide (21D1) Docetaxel (21D1) (575 VER 02-18-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 08-24-16 (575 VER: 02-18-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cyclophosphamide/Docetaxel
Disease Group: Breast
Disease: Breast Cancer (Adjuvant)

Therapy: DOCEtaxel 75 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1,

Cycle Length: 21 days Course: 4 cycles

Reference(s): Jones SE, et al. Proc of the 28
th
SABCS 2005;40.

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
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored every 15 minutes for the 1
st
and 2
nd
DOCEtaxel administration and then every 30
minutes for any subsequent doses.
• 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:
• 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) 16 mg by mouth once. PO preferred – may give 8 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:



VER: 08-24-16 (575 VER: 02-18-15) Page 2 of 2
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:


• DOCEtaxel (Taxotere) __________mg (75 mg/m2) in non-PVC Bag IV once through non-PVC tubing.
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a
location to optimize emergency care.

• cyclophosphamide (Cytoxan) ____________ mg (600 mg/m2) IV once over 30 to 60 minutes.

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 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.

 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:
 Other:

• Procedures/Imaging/Scans:



• Other Orders:



MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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