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GI Bevacizumab (28D1,15) Fluorouracil (28D1,15) Oxaliplatin (28D1,15) (383 VER: 04-19-13)

GI Bevacizumab (28D1,15) Fluorouracil (28D1,15) Oxaliplatin (28D1,15) (383 VER: 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-27-16 (383 VER: 04-19-13) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bevacizumab/Fluorouracil/Oxaliplatin (Bevacizumab-FOLFOX)
Disease Group: Gastrointestinal
Disease: Colon and Rectal Cancer (Advanced)

Therapy: oxaliplatin 85 mg/m2 IV Day 1 and 15,
leucovorin 175 mg/m2 IV Day 1 and 15,
bevacizumab 5 mg/kg IV Day 1 and 15,
fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours.
(Total dose = 2400 mg/m2 IV over 46 hours per home infusion) on Day 1 and 15;

Cycle Length: 28 days Course: 6 cycles

Reference(s): André T, et al. N Engl J Med 2004;350(23):2343-51; Cheeseman SL, et al. Br J Cancer 2002;87(4):393-9.

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, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Urinalysis without microscopy, Carcinoembryonic Antigen (CEA)
 Other:


• Day 15: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1: WBC, ANC, Platelets, Urine Protein
 Day 15: CBC, ANC
• Hold and notify authorizing provider for:
• Day 1: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Urine Protein ≥ 100 mg/dL or Blood Pressure ≥ 160/90
mmHg.
• Day 15: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Blood Pressure ≥ 160/90 mmHg.
• Check for mucositis, irritation of hands or feet, or diarrhea.

Nursing Procedure, Assessment and Monitoring:
• Educate/reinforce with patient regarding hand and foot syndrome related to continuous fluorouracil infusion
and to call with concerns.
• Educate/reinforce with patient regarding “cold neuropathy” that occurs with oxaliplatin.
• Flush/Line Care per Institution standards
• Disconnect pump upon completion of 46 hour fluorouracil infusion on Day 3 and 17
 In Clinic  At Home By Patient  At Home by Home Health Nurse  Other _______________

VER: 09-27-16 (383 VER: 04-19-13) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Hydration/Fluid:
• dextrose 5% in water IV to establish line and for flushing (for oxaliplatin)
• sodium chloride 0.9% IV to establish line and for flushing

Pre Medications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth 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:










• oxaliplatin (Eloxatin) __________mg (85 mg/m2) IV once over 120 minutes. Hypersensitivity to oxaliplatin can
occur. For first and second dose, patient should be treated in a location to optimize emergency care.
NOTE: Incompatible with sodium chloride. Allow adequate flushing with Dextrose 5% in Water.

• leucovorin ____________ mg (175 mg/m2) IV once over 120 minutes. leucovorin may be administered (via
separate infusion lines) concurrently with oxaliplatin.

• bevacizumab (Avastin) __________ mg (5 mg/kg) IV once over 10 minutes. Hypersensitivity to bevacizumab
can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Patient must be monitored for 30 minutes after first dose of bevacizumab. NOTE: Incompatible with dextrose.

• fluorouracil (Adrucil) ____________ mg (400 mg/m2) IV bolus once over 5 to 15 minutes.

• fluorouracil (Adrucil) ____________ mg (2400 mg/m2) continuous IV infusion over 46 hours.



Treatment Medications (continued on next page)


VER: 09-27-16 (383 VER: 04-19-13) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:









• oxaliplatin (Eloxatin) __________mg (85 mg/m2) IV once over 120 minutes. Hypersensitivity to oxaliplatin can
occur. For first and second dose, patient should be treated in a location to optimize emergency care.
NOTE: Incompatible with sodium chloride. Allow adequate flushing with Dextrose 5% in Water.

• leucovorin ____________ mg (175 mg/m2) IV once over 120 minutes. leucovorin may be administered (via
separate infusion lines) concurrently with oxaliplatin.

• bevacizumab (Avastin) __________ mg (5 mg/kg) IV once over 10 minutes. Hypersensitivity to bevacizumab
can occur. For first and second dose, patient should be treated in a location to optimize emergency care.
Patient must be monitored for 30 minutes after first dose of bevacizumab. NOTE: Incompatible with dextrose.

• fluorouracil (Adrucil) ____________ mg (400 mg/m2) IV bolus once over 5 to 15 minutes.

• fluorouracil (Adrucil) ____________ mg (2400 mg/m2) continuous IV infusion over 46 hours.

Other Orders for Day 1 and/or Day 15:






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 for 3 days following start of fluorouracil infusion.

• 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: 09-27-16 (383 VER: 04-19-13) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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 #: ________