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Lung Cisplatin (21D1) Pemetrexed (21D1) (50 VER: 10-3-16)

Lung Cisplatin (21D1) Pemetrexed (21D1) (50 VER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 11-8-16 (50 VER: 10-3-16) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Pemetrexed
Disease Group: Lung
Disease: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Squamous, Non-Small Cell Lung Cancer
(Adjuvant/Advanced)

Therapy: pemetrexed 500 mg/m2 IV Day 1,
CISplatin 75 mg/m2 IV Day 1,
folic acid at least 300 mcg by mouth once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed,
cyanocobalamin 1 mg IM once every 9 weeks to begin at least 1 week prior to pemetrexed and to
continue until pemetrexed is discontinued

Cycle Length: 21 days

Course: 4 to 6 cycles

Reference(s): Vogelzang NJ, et al. J Clin Oncol 2003;21:2636-44, Shepherd FA, et al. Cancer 2001;92:595-600, Scagliotti
GV, et al. J Clin Oncol 2008; 26:3543-51.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

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



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC, Creatinine
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Creatinine Clearance < 45 mL/minute
• Verify that patient has taken home folic acid and dexamethasone and document.
• Cycle 1 Day 1: Verify that patient received cyanocobalamin prior to first pemetrexed dose and document.

Nursing Procedure, Assessment and Monitoring:
• Measure IV intake and urine output.
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV administer 1000 mL throughout chemotherapy
 Additional additives required – these may be added to any appropriate fluid throughout treatment
 Magnesium ______ grams
 Potassium chloride ______ mEq



Final Approved VER: 11-8-16 (50 VER: 10-3-16) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:



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:



 cyanocobalamin (Vitamin B12) 1 mg IM to be given once every 9 weeks (i.e., at least one week prior to first
dose of pemetrexed and with every 3
rd
cycle (i.e., Cycle 3 and 6)

• pemetrexed (Alimta) __________mg (500 mg/m2) IV once over 10 minutes

• CISplatin (Platinol) __________mg (75 mg/m2) IV once over 30 to 60 minutes

Conditional Orders Day 1:
• furosemide (Lasix) 20 mg IV once PRN. Administer if intake is greater than 2000 mL and urine output less
than 500 mL.

Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #48, Refills: 5
Take 1 tablet (4 mg) by mouth twice daily the day prior, day of and day after chemo, then 2 tabs once daily for
2 days.

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

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 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:


Final Approved VER: 11-8-16 (50 VER: 10-3-16) 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 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 #: ________