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GI Capecitabine 1250 mg per m2(21D 1-14) (400 Ver 04-19-13)

GI Capecitabine 1250 mg per m2(21D 1-14) (400 Ver 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-08-16 (400 VER: 04-19-13) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Title: Capecitabine
Disease Group: Gastrointestinal
Disease: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT

Therapy: capecitabine 1250 mg/m2 by mouth twice daily Day 1 through 14 followed by 7 days rest

Cycle Length: 21 days Course: Adjuvant - 8 cycles, Advanced - until disease progression

Reference(s): Twelves C, et al. N Engl J Med 2005;352:2696-701; Hoff P, et al. J Clin Oncol 2001;19:2282-92

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
 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 authorizing provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL

Nursing Procedure, Assessment and Monitoring:
• Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.

Hydration/Fluids: None

Premedications/Antiemetics: None

Treatment Medications for Day 1: Refer to Take Home Medications section

Other Orders for Day 1:










VER: 09-08-16 (400 VER: 04-19-13) Page 2 of 2
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)

• capecitabine (Xeloda) 1250 mg/m2 by mouth 2 times daily for 14 days. (Round dose to available tablet sizes of 500
mg and 150 mg.)

Take ______ mg in AM and ______ mg in PM daily beginning evening of __________ (date) through morning of
____________ (date).

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


Follow Up
• Clinic Visit: Day 1 every 21 days

• Labs: None
 Other:



• Procedures/Imaging/Scans:










• Other Orders:










MD Signature_____________________________ Pager______________
Date _____________Time______________

Order verification:
RN Signature: _______________________ Date: __________ Time: ______ Pager #: ________
RPh Signature: ______________________ Date: __________ Time: ______ Pager #: ________