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Head Neck Concurrent XRT Cetuximab(21D1,8,15) (977 VER: 10-03-16)

Head Neck Concurrent XRT Cetuximab(21D1,8,15) (977 VER: 10-03-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 11-11-16 (977 VER: 10-03-16) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cetuximab with concurrent XRT
Disease Group: Head/Neck
Disease: Locally Advanced Squamous Cell Head and Neck Cancer

Therapy: cetuximab 400 mg/m2 IV Loading Dose 1 week prior to radiotherapy, followed by
cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of radiotherapy

Cycle Length: 21 days Course: 2 cycles or until the end of radiotherapy

Reference(s): Bonner JA, et al. N Engl J Med 2006;354:567-78

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 8 (date) ___________
 Day 15 (date) __________

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

• Day 8 and 15: Obtain Magnesium, Potassium
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1: CBC, ANC, Creatinine
 Day 8 and 15: Magnesium, Potassium
• Hold and notify provider for: Day 1: ANC ≤ 1500/µL or Platelets ≤ 100K/µL or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Cycle 1, Day 1 and 8: Vital Signs to be monitored every 15 minutes for the first hour and then every 30
minutes until infusion complete. Nurse should remain with patient for the first 15 minutes of drug administration
for the first and second dose of cetuximab administration.
• Cycle 1, Day 15 and Cycles 2+: Vital signs to be monitored every 30 minutes until infusion complete if first
and second administration without hypersensitivity reaction. If history of hypersensitivity reaction, increase vital
sign monitoring and frequency of nursing assessment.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to cetuximab:
• acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 50 mg IV once.
 Other:


VER: 11-11-16 (977 VER: 10-03-16) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 Cycle 1: cetuximab (Erbitux) __________mg (400 mg/m2) IV once over 120 minutes through 0.22 micron in-
line filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity reaction to cetuximab can occur. For first
and second dose, patient should be treated in a location to optimize emergency care. PATIENT MUST
REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF THE FIRST
DOSE.

 Cycle 2+: cetuximab (Erbitux) __________mg (250 mg/m2) IV once over 60 minutes (if tolerated from
previous doses) through 0.22 micron in-line filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.


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


• cetuximab (Erbitux) __________mg (250 mg/m2) IV once over 60 minutes (if tolerated from previous doses)
through 0.22 micron in-line filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity reaction to
cetuximab can occur. For first and second dose, patient should be treated in a location to optimize emergency
care.


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


• cetuximab (Erbitux) __________mg (250 mg/m2) IV once over 60 minutes (if tolerated from previous doses)
through 0.22 micron in-line filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity reaction to
cetuximab can occur. For first and second dose, patient should be treated in a location to optimize emergency
care.



Other Orders for Day 1, 8 and/or 15:








VER: 11-11-16 (977 VER: 10-03-16) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #20, 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.

 Other:





Follow Up
• Chemotherapy: Day 1, 8 and 15 every 21 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 #: ________