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Gyn Doxorubicin(21D1) (6206 Ver 10-3-16) (Part 2 of 2)

Gyn Doxorubicin(21D1) (6206 Ver 10-3-16) (Part 2 of 2) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 10-26-16 (6206 VER: 10-03-16) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Doxorubicin
Disease Group: Gynecology/Oncology
Disease: High-Grade Uterus-Limited Leiomyosarcoma (Adjuvant)

Therapy: doxorubicin 60 mg/m2 IV Day 1

Cycle Length: 21 days Course: 4 cycles

Note: This regimen follows treatment with DOCEtaxel-gemcitabine only if CT scan shows no evidence of
disease.

Reference(s): Hensley ML, et al. Cancer 2013;119(8):1555-61

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, AST, ALT, Total Bilirubin
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC, Total Bilirubin
• Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL or Total Bilirubin > ULN
• Cycle 1 only: Verify patient has obtained pretreatment MUGA or ECHO.

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

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

Premedications/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:


• doxorubicin (Adriamycin) __________mg (60 mg/m2) IV once by side arm push at 3 to 5 mL/minute into
running IV.

VER: 10-26-16 (6206 VER: 10-03-16) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth two times daily for 2 days after chemotherapy and every 8 hours as needed
thereafter.

• ranitidine (Zantac) 150 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (150 mg) by mouth two times daily.

 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:

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 #: ________