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Lung Cyclophosphamide(21D1) DOXOrubicin(21D1) Vincristine(21D1) (345 VER 3-5-15)

Lung Cyclophosphamide(21D1) DOXOrubicin(21D1) Vincristine(21D1) (345 VER 3-5-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-13-16 (345 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Title: Cyclophosphamide/Doxorubicin/Vincristine
Disease Group: Lung
Disease: Small Cell Lung Cancer (Advanced)

Therapy: doxorubicin 45 mg/m2 IV Day 1,
vinCRIStine 2 mg IV Day 1,
cyclophosphamide 1000 mg/m2 IV Day 1

Cycle Length: 21 days Course: 4 to 6 cycles

Reference(s): Shepherd FA, et al. Cancer Treat Rep 1987;71:941-4; Roth BJ, et al. J Clin Oncol 1992;10:282-91.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase
 Other:



Treatment Conditions:
• Verify the following labs have been obtained: CBC, ANC
• Hold and notify authorizing provider for: ANC < 1000/µL or Platelets < 100K/µL

Nursing Procedure, Assessment and Monitoring:
• RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after
treatment
• Flush/Line Care per Institution standards

Hydration/Fluids:
• sodium chloride 0.9% IV administer 2000 mL throughout chemotherapy

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:


VER: 09-13-16 (345 VER: 03-05-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Treatment Medications: (In order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• doxorubicin (Adriamycin) _____________ mg (45 mg/m2) IV once by side arm push over
3 to 5 mL/minute into running IV.

• vinCRIStine (Oncovin) 2 mg IV once over 3 to 5 minutes. Must be administered via gravity through a
peripheral IV (not on an infusion pump).

• cyclophosphamide (Cytoxan) ___________ mg (1000 mg/m2) IV once over 30 to 60 minutes.



Other Orders:




Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #24, Refills: 5
Take 2 tablets (8 mg) by mouth once 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 (80 mg) by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

 Other:






VER: 09-13-16 (345 VER: 03-05-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Follow Up
• Chemotherapy: Day 1 every 21 days

• Labs:
 Day 10 – Obtain CBC, ANC (DIFF if to be done locally)
 Other:





• Procedures/Imaging/Scans:













• Other Orders:















MD Signature_____________________________ Pager______________
Date _____________Time______________

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