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Breast Docetaxel(21D1) Pertuzumab(21D1) Trastuzumab(21D1) (4795 Ver 09-28-15)

Breast Docetaxel(21D1) Pertuzumab(21D1) Trastuzumab(21D1) (4795 Ver 09-28-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 09-08-16 (4795 VER: 09-28-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Docetaxel/Pertuzumab/Trastuzumab
Disease Group: Breast
Disease: Breast Cancer (Neoadjuvant/Adjuvant), Metastatic Breast Cancer (Advanced)

Therapy:
Cycle 1
pertuzumab 840 mg IV Day 1,
trastuzumab 8 mg/kg IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1
Cycle ≥ 2
pertuzumab 420 mg IV Day 1,
trastuzumab 6 mg/kg IV Day 1,
DOCEtaxel 75 to 100 mg/m2 IV Day 1

Cycle Length: 21 days
Course: Neoadjuvant/Adjuvant - 3 to 4 cycles, Advanced - until disease progression

Reference(s): Baselga J, et al. N Engl J Med 2012;366(2):109-19. Gianni L, et al. Lancet Oncol 2012;13(1):25-32.
Schneeweiss A, et al. Ann Oncol 2013;24(9):2278-84. Swain SM, et al. Lancet Oncol 2013;14(6):461-71.
Untch M, et al. J Clin Oncol 2011;29(25):3351-7.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

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


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC, Platelets, Creatinine, AST, Total Bilirubin
• Hold and notify provider for: ANC < 1000/µL or Platelets ≤ 100K/µL or Creatinine > 1.5 X ULN or AST > 2.5 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 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 to establish line and for flushing





Final Approved VER: 09-08-16 (4795 VER: 09-28-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics
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) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 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:

 Cycle 1
• pertuzumab (Perjeta) 840 mg IV once over 60 minutes. Do NOT administer by rapid push or bolus.
Hypersensitivity risk. For first and second dose patient should be treated in a location to optimize emergency
care. Patient must be monitored for 30 minutes after the first dose. No additional medications to be
administered during observation period.

• trastuzumab (Herceptin) ____________ mg (8 mg/kg) IV once. Give first dose over 90 minutes and
subsequent doses over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient must be monitored for one hour after the first dose of
trastuzumab. Trastuzumab should be given PRIOR to any chemotherapy.

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



 Cycle ≥ 2
• pertuzumab (Perjeta) 420 mg IV once over 30 to 60 minutes. Do NOT administer by rapid push or bolus.
Hypersensitivity risk. For first and second dose patient should be treated in a location to optimize emergency
care.

• trastuzumab (Herceptin) ____________ mg (6 mg/kg) IV once over 30 minutes. Hypersensitivity risk. For first
and second dose, patient should be treated in a location to optimize emergency care. Trastuzumab should be
given PRIOR to any chemotherapy.

• DOCEtaxel (Taxotere) __________ mg (Dosed at ________ mg/m2 (75 to 100 mg/m2)) IV once over 60
minutes in non-PVC bag and non-PVC tubing. Hypersensitivity risk. For first and second dose, patient should
be treated in a location to optimize emergency care.


Other Orders for Day 1:





Final Approved VER: 09-08-16 (4795 VER: 09-28-15) 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)
• 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.

 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 #: ________