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Hem Bortezomib (21D:1,4,8,11)-Dexamethasone (21D:1,2,4,5,8,9,11,12) (1073 VER: 10-23-15)

Hem Bortezomib (21D:1,4,8,11)-Dexamethasone (21D:1,2,4,5,8,9,11,12) (1073 VER: 10-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-22-16 (1073 VER: 10-23-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bortezomib/Dexamethasone
Disease Group: Hematology
Disease: Myeloma

Therapy: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11;
dexamethasone 20 mg (fixed dose) by mouth Day 1, 2, 4, 5, 8, 9, 11, and 12

Cycle Length: 21 days Course: 6 cycles

References: Jagannath S, et al. Br J Hematology; 2005;29(6):776-83, Moreau P, et al. Lancet Oncol 2011;12:431-40.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 4 (date) ___________
 Day 8 (date) ___________  Day 11 (date) ___________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Total Bilirubin, AST
 Other:




Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC
• Hold and notify provider for ANC ≤ 1,000/µL and Platelets ≤ 75K/µL
• Verify that patient has taken dexamethasone and document.


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


Hydration/Fluids: Flush/Line Care per Institution standards


Premedications/Antiemetics: (May substitute formulary equivalent) - None




VER: 09-22-16 (1073 VER: 10-23-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:


• dexamethasone (Decadron) 20 mg by mouth once prior to bortezomib. Omit if taken at home.

• bortezomib (Velcade) _________mg (1.3 mg/m2) subcutaneous once



Treatment Medications for Day 4: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 20 mg by mouth once prior to bortezomib. Omit if taken at home.

• bortezomib (Velcade) _________mg (1.3 mg/m2) subcutaneous once



Treatment Medications for Day 8: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 20 mg by mouth once prior to bortezomib. Omit if taken at home.

• bortezomib (Velcade) _________mg (1.3 mg/m2) subcutaneous once



Treatment Medications for Day 11: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 20 mg by mouth once prior to bortezomib. Omit if taken at home.

• bortezomib (Velcade) _________mg (1.3 mg/m2) subcutaneous once



Other Orders for Day 1, 4, 8 and/or 11:




VER: 09-22-16 (1073 VER: 10-23-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications
• dexamethasone (Decadron) tablet 4 mg Disp # 40
Take 5 tablets (20 mg) by mouth on Day 1, 2, 4, 5, 8, 9, 11, and 12.
NOTE: Day 1, 4, 8 and 11 doses may be given in clinic as premedication.

• acyclovir (Zovirax) 400 mg tablet, Disp #60; Refills: 5
Take 1 tablet (400 mg) by mouth twice daily to prevent viral infection

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

 Other:



Follow Up
• Chemotherapy: Day 1, 4, 8, and 11 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 #: ________