/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/ppo/,

/clinical/cckm-tools/content/ppo/name-111338-en.cckm

20170102

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Preprinted Paper Orders

Breast Paclitaxel(21D:1,8,15)/Trastuzumab(21D:1,8,15) (5649 VER: 10-03-16) (Part 2 of 3)

Breast Paclitaxel(21D:1,8,15)/Trastuzumab(21D:1,8,15) (5649 VER: 10-03-16) (Part 2 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 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Paclitaxel/Trastuzumab
Disease Group: Breast
Disease: Breast Cancer (Adjuvant)

Therapy:
Cycle 1: trastuzumab 4 mg/kg IV Day 1,
PACLItaxel 80 mg/m2 IV Days 1, 8, 15
trastuzumab 2 mg/kg IV Days 8, 15

Cycle 2, 3, and 4: trastuzumab 2 mg/kg IV Day 1, 8, 15
PACLItaxel 80 mg/m2 IV Days 1, 8, 15

Cycle Length: 21 days Course: 4 cycles

NOTE: This regimen follows treatment with cyclophosphamide/doxorubicin and may be followed by continued
therapy with single-agent trastuzumab. 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) __________ Day 8 (date) __________ Day 15 (date) _________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin
 Other:


• Day 8 and 15: Obtain CBC without DIFF, ANC
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1: CBC, ANC, Creatinine, AST, Total Bilirubin
 Day 8 and 15: CBC, ANC
• Hold and notify authorizing prescriber for:
 Day 1: ANC ≤ 1,000/µL or Platelets ≤ 100K/µL or Creatinine > 1.5 X ULN or Total Bilirubin ≥ to 1.25 X
ULN or AST ≥ 5 X ULN
 Day 8 and 15: ANC < 1,000/µL or Platelets < to 100K/µL.
• Verify that patient has taken dexamethasone and document.










VER: 12-28-16 (5649 VER: 10-03-16) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion
complete for the first and second dose of PACLItaxel administration. Monitor vital signs every 30 minutes for
all subsequent doses if previous doses tolerated.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to PACLItaxel:
• diphenhydramine (Benadryl) 50 mg IV once.
• ranitidine (Zantac) 50 mg IV once.
• dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take dexamethasone at
home.
 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:




 Cycle 1, Day 1:
• trastuzumab (Herceptin) __________ mg (4 mg/kg) IV once over 60 minutes. Give prior to any chemotherapy.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize emergency
care. Patient must be monitored for one hour after the first dose of trastuzumab.



• PACLItaxel (Taxol) __________ mg (80 mg/m2) IV once over 60 minutes. Use non-PVC tubing and standard
in-line filter during administration. Hypersensitivity risk. For first and second dose, patient should be treated in
a location to optimize emergency care.


 Cycle ≥ 2, Day 1:
• trastuzumab (Herceptin) __________ mg (2 mg/kg) IV once over 30 minutes. Give prior to any chemotherapy.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize emergency
care.

• PACLItaxel (Taxol) __________ mg (80 mg/m2) IV once over 60 minutes. Use non-PVC tubing and standard
in-line filter during administration. Hypersensitivity risk. For first and second dose, patient should be treated in
a location to optimize emergency care.

Treatment Medications (continued on next page)




VER: 12-28-16 (5649 VER: 10-03-16) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

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:




• trastuzumab (Herceptin) __________ mg (2 mg/kg) IV once over 30 minutes. Give prior to any chemotherapy.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize emergency
care.

• paclitaxel (Taxol) __________ mg (80 mg/m2) IV once over 60 minutes. Use non-PVC tubing and standard
in-line filter during administration. Hypersensitivity risk. For first and second dose, patient should be treated in
a location to optimize emergency care.


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




• trastuzumab (Herceptin) __________ mg (2 mg/kg) IV once over 30 minutes. Give prior to any chemotherapy.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize emergency
care.

• PACLItaxel (Taxol) __________ mg (80 mg/m2) IV once over 60 minutes. Use non-PVC tubing and standard
in-line filter during administration. Hypersensitivity risk. 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: 12-28-16 (5649 VER: 10-03-16) Page 4 of 4
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)
• dexamethasone (Decadron) 4 mg tablet Disp. #60, Refills: 1
Take 5 tablets (20 mg) by mouth 12 and 6 hours prior to the 1
st
PACLItaxel dose, then 3 tablets (12 mg) by
mouth 12 and 6 hours prior to the 2
nd
PACLItaxel dose and 2 tablets (8 mg) by mouth 12 and 6 hours prior to
remaining PACLItaxel doses.

 Other:




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

• Labs: None
 Other:




• Procedures/Imaging/Scans:












• Other Orders:









MD Signature_____________________________ Pager______________
Date _____________Time ________________

Order verification:
RN Signature: _________________ Date: _______ Time: ______ Pager #: ________
RPh Signature: ________________ Date: _______ Time: ______ Pager #: ________