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Gyn Bevacizumab 28D:1,15 (1791 VER: 06-15-15)

Gyn Bevacizumab 28D:1,15 (1791 VER: 06-15-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-22-16 (1791 VER: 06-15-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bevacizumab
Disease Group: Gynecology/Oncology
Disease: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced)

Therapy: Bevacizumab 10 mg/kg IV Day 1 and 15

Cycle Length: 28 days Course: until disease progression

Reference(s): Monk BJ et al. Gynecol Oncol 2005;96:902-5.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 15 (date) ___________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, Creatinine, CA 125, Urinalysis (no microscopy)

Treatment Conditions:
• Day 1: Verify the following labs have been obtained: Urine protein
• Day 1: Hold and notify authorizing provider for: Urine protein ≥ 100 mg/dL or Blood Pressure ≥ 160/90 mmHg
• Day 15: Hold and notify authorizing provider for: Blood Pressure ≥ 160/90 mmHg

Nursing Procedure, Assessment and Monitoring: Flush/Line Care per Institution standards

Hydration: sodium chloride 0.9% IV to establish line and for flushing

Pre Medications: None

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:



• bevacizumab (Avastin) ____________ mg (10 mg/kg) IV once. First dose over 90 minutes. If tolerated, give
2
nd
dose over 60 minutes; if tolerated, give 3
rd
and subsequent doses over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well
tolerated. Hypersensitivity to bevacizumab can occur. For first and second dose, patient should be treated in
a location to optimize emergency care.

Treatment Medications for Day 15: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bevacizumab (Avastin) ____________ mg (10 mg/kg) IV once. First dose over 90 minutes. If tolerated, give
2
nd
dose over 60 minutes; if tolerated, give 3
rd
and subsequent doses over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well
tolerated. Hypersensitivity to bevacizumab can occur. For first and second dose, patient should be treated in
a location to optimize emergency care.

VER: 09-22-16 (1791 VER: 06-15-15) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Other Orders for Day 1 and/or 15:




Take Home Medications
 Other:



Follow Up
• Chemotherapy: Day 1 and 15 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 #: ________