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GI Regorafenib(28D 1-21) Oral (5015 Ver 07-21-15)

GI Regorafenib(28D 1-21) Oral (5015 Ver 07-21-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders





VER: 09-08-16 (5015 VER: 07-21-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Regorafenib
Disease Group: Gastrointestinal
Disease: Colorectal Cancer (Advanced), Gastrointestinal Stromal Tumor (GIST) (Advanced)

Therapy: regorafenib 160 mg by mouth once daily on Days 1 through 21

Cycle Length: 28 days Course: Until disease progression

NOTE: For use as 3
rd
line treatment for metastatic colorectal cancer in patients previously treated with
fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, anti-VEGF therapy, or anti-EGFR therapy (if
KRAS wild type). For use in GIST patients who have previously been treated with imatinib and sunitinib.

Reference(s): Grothey A, et al. Lancet 2013;381(9863):303-12; Demetri GD, et al. Lancet 2013;381(9863):295-302.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2

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

Pre labs: Obtain CBC without DIFF, ANC, Total Bilirubin, AST, ALT, Alkaline Phosphatase

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: AST, ALT
• Hold and notify authorizing provider for: Systolic Blood Pressure > 140 mmHg or Diastolic Blood Pressure >
90 mmHg or AST > 5 X ULN or ALT > 5 X ULN.

Nursing Procedure, Assessment and Monitoring:
• Blood pressure checks are required weekly for 6 weeks and then monthly thereafter unless more frequent
blood pressure checks are clinically indicated. Instruct patient to call clinic for Systolic Blood Pressure greater
than 140 mmHg or Diastolic Blood Pressure greater than 90 mmHg.
• Educate/reinforce with patient regarding hand and foot syndrome related to regorafenib and to call with
concerns.

Hydration/Fluid: None

Premedications/Antiemetics: None

Treatment Medications: Refer to Take Home Medications section

Other Orders for Day 1:













VER: 09-08-16 (5015 VER: 07-21-15) 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)
• regorafenib (Stivarga) 40 mg tablet, Disp. #84, Refills: ______
Take 4 tablets (160 mg) by mouth once daily on Days 1 through 21. Keep in original bottle with desiccant.
Expires 7 weeks after opening.

 Other:




Follow Up
• Clinic Visit: Day 1 every 28 days

• Labs:
 Cycle 1 and Cycle 2, Day 15 – Obtain AST, ALT, Total Bilirubin
 Other:



• Procedures/Imaging/Scans:












• Other Orders:








MD Signature_____________________________ Pager______________
Date _____________Time______________

Order verification:
RN Signature: _________________ Date: _______ Time: ______ Pager #: ________
RPh Signature: ________________ Date: _______ Time: ______ Pager #: ________