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Breast Cyclophosphamide(14D:1)/Doxorubicin(14D:1) (5649 VER: 10-03-16) (Part 1 of 3)

Breast Cyclophosphamide(14D:1)/Doxorubicin(14D:1) (5649 VER: 10-03-16) (Part 1 of 3) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 12-28-16 (5649 VER: 10-03-16) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cyclophosphamide/Doxorubicin
Disease Group: Breast
Disease: Breast Cancer (Adjuvant)

Therapy: doxorubicin 60 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1,
GROWTH FACTOR REQUIRED

Cycle Length: 14 days Course: 4 cycles

Note: This regimen is followed by trastuzumab and PACLItaxel. See additional preprinted orders.

Reference(s): Citron ML, et al. J Clin Oncol 2003;21:1431-39; Romond E, et al. N Eng J Med
2005;353(16):1673-84; Leyland-Jones B, et al. J Clin Oncol 2003;21(21):3965-71

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC without DIFF, ANC, Creatinine, Total Bilirubin, AST
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Creatinine > 2 mg/dL or AST > 1.5 X
ULN or Total Bilirubin > 1.2 mg/dL
• Cycle 1 only: Verify patient has obtained pretreatment MUGA or ECHO.

Nursing Procedure, Assessment and Monitoring:
• RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after
treatment.
• 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) 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:


VER: 12-28-16 (5649 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: (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.

• cyclophosphamide (Cytoxan) ____________ mg (600 mg/m2) IV once over 30 to 60 minutes.


Other Orders for Day 1:





Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ranitidine (Zantac) 150 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (150 mg) by mouth two times daily.

• dexamethasone (Decadron) 4 mg tablet, Disp. #24, Refills: 0
Take 2 tablets (8 mg) by mouth once daily for 3 days following chemotherapy.

• 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: 3
Take 1 capsule by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

Select One: (May substitute formulary equivalent)
 filgrastim (Neupogen) 300 mcg/0.5 mL syringe. Disp. 10 syringes, Refills: 5
Inject one syringe (300 mcg) under skin one time daily in evening beginning Day _____ and continue until
ANC is greater than ______ after nadir.

 filgrastim (Neupogen) 480 mcg/0.8 mL syringe. Disp. 10 syringes, Refills: 5
Inject one syringe (480 mcg) under skin one time daily in evening beginning Day _____ and continue until
ANC is greater than ______ after nadir.


 Other:









VER: 12-28-16 (5649 VER: 10-03-16) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 every 14 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 #: ________