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GI Cisplatin(28D 1) Fluorouracil(28D 1-4) (429 Ver 04-19-13)

GI Cisplatin(28D 1) Fluorouracil(28D 1-4) (429 Ver 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-08-16 (429 VER: 04-19-13) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Fluorouracil
Disease Group: Gastrointestinal
Disease: Esophagus and Gastroesophageal Junction Cancer (Adjuvant), Anal Cancer (Adjuvant/Advanced)

Therapy: CISplatin 75 mg/m2 IV Day 1
fluorouracil 4000 mg/m2 administered as a continuous infusion IV over 96 hours
(Total dose = 4000 mg/m2 IV over 96 hours per home infusion) on Day 1.

Cycle Length: 28 days Course: 4 cycles

NOTE: Dose varies from Herskovic reference. Therapy for anal cancer patients who are NOT candidates for
mitomycin based therapy. This protocol may be used with or without concurrent XRT.

Reference(s): Herskovic A, et al. N Engl J Med 1992;326(24):1593-8; Ajani JA, et al. J Clin Oncol 2006;24(18S):4009.

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, Magnesium
 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 or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Check for mucositis, irritation of hands or feet, or diarrhea.
• Measure IV intake and urine output.
• Flush/Line Care per Institution standards
• Disconnect pump upon completion of 96 hour fluorouracil infusion on Day 5
 In Clinic  At Home By Patient  At Home by Home Health Nurse  Other _______________


Hydration/Fluids:
• sodium chloride 0.9% with Potassium Chloride 20 mEq IV administer 1000 mL throughout chemotherapy







VER: 09-08-16 (429 VER: 04-19-13) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 24 mg by mouth once. PO preferred – may give 12 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 12 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 *aprepitant (Emend) 125 mg by mouth once.
 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:

• CISplatin (Platinol) ____________ mg (75 mg/m2) IV once over 60 to 90 minutes.

• fluorouracil (Adrucil) ____________ mg (4000 mg/m2) continuous infusion IV once over 96 hours.



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. #24 tablets, Refills: 5
Take 2 tablets (8 mg) by mouth one time daily for 3 days following chemotherapy.

• 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:











VER: 09-08-16 (429 VER: 04-19-13) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 every 28 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 #: ________