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GI CISPLATIN(21D1) GEMCITABINE(21D1) (3085 VER: 10-3-16)

GI CISPLATIN(21D1) GEMCITABINE(21D1) (3085 VER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 11-17-16 (3085 VER: 10-3-16) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Gemcitabine
Disease Group: GI
Disease: Biliary Carcinomas (Advanced)

Therapy: gemcitabine 1000 mg/m2 IV Day 1 and 8,
CISplatin 25 mg/m2 IV Day 1 and 8

Cycle Length: 21 days Course: 8 cycles

Reference(s): Valle JW, et al. J Cancer 2009;101(4):621-7, Eckel F, et al. Br J Cancer 2007;96(6):896-902

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Magnesium, Potassium, Creatinine
 Other:

• Day 8: Obtain CBC without DIFF, ANC, Creatinine
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1 and 8: Verify the following labs have been obtained: CBC, ANC, Creatinine
• Day 1 and 8: Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Measure urine output and IV intake. If IV intake is greater than 2000 mL and urine output less than 500 mL,
give furosemide. See conditional orders.
• Flush/Line Care per Institution standards

Hydration/Fluids:
• Sodium chloride 0.9% IV administer 1000 mL throughout chemotherapy

Premedications/Antiemetics
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *aprepitant (Emend) 125 mg by mouth once.
 *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.
 fosaprepitant (Emend) 150 mg IV once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:




Final Approved VER: 11-17-16 (3085 VER: 10-3-16) 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:


• gemcitabine (Gemzar) __________mg (1000 mg/m2) IV once over 30 minutes
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.

• CISplatin (Platinol) ____________ mg (25 mg/m2) IV once over 60 minutes


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:


• gemcitabine (Gemzar) __________mg (1000 mg/m2) IV once over 30 minutes
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.

• CISplatin (Platinol) ____________ mg (25 mg/m2) IV once over 60 minutes


Conditional Orders Day 1 and 8:
• 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 and/or 8:





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 CISplatin.

• 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. #4, Refills: 7
Take 1 capsule by mouth once daily for two days following CISplatin.
(Prescribe only if patient received aprepitant as a premedication)

 Other:




Final Approved VER: 11-17-16 (3085 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 and 8 every 21 days

• Labs:
 Day 15 – 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 #: ________