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

/clinical/cckm-tools/content/ppo/name-111675-en.cckm

20170117

page

100

UWHC,UWMF,

Tools,

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

GU Bleomycin (21D1,8,15) Cisplatin (21D1-5) Etoposide (21D1-5) (953 VER: 12-1-16)

GU Bleomycin (21D1,8,15) Cisplatin (21D1-5) Etoposide (21D1-5) (953 VER: 12-1-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 01-12-17 (953 VER: 12-1-16) Page 1 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bleomycin/Cisplatin/Etoposide
Disease Group: Genitourinary
Disease: Testicular/Germ Cell Cancer (Adjuvant/Advanced)

Therapy: bleomycin 30 units (FIXED DOSE) IV Day 1, 8 and 15,
CISplatin 20 mg/m2 IV Day 1 through 5
etoposide 100 mg/m2 IV Day 1 through 5

Cycle Length: 21 days Course: 3 to 4 cycles

Reference(s): Bosi GJ, et al. J Clin Oncol 1988;6:1231-8, Williams SD, et al. N Engl J Med 1987;316:1435-40,
Culine S, et al. Proc Am Soc Clin Oncol 2003;abstract 1536

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1, Day 1: Obtain CBC without DIFF, ANC, Potassium, Creatinine, Magnesium, AFP (tumor marker,
serum), HCG (quantitative), LDH
 Other:


• Cycle ≥ 2, Day 1: Obtain CBC without DIFF, ANC, Potassium, Creatinine, Magnesium
 AFP (tumor marker, serum), HCG (quantitative), LDH – per MD discretion
 Other:


• All Cycles, Day 4: Obtain Potassium, Magnesium, Creatinine, Phosphate
 Other:


• All Cycles, 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
 Day 4: Magnesium, Potassium
 Day 8 and 15: CBC, ANC
• Hold and notify provider for:
 Day 1: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Creatinine > ULN
 Day 4: Any prelab results not within normal limits
 Day 8 and 15: ANC ≤ 1000/µL or Platelets ≤ 75K/µL
• Day 8 and 15: Check patient for mouth sores prior to administration of chemotherapy.

VER: 01-12-17 (953 VER: 12-1-16) Page 2 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Nursing Procedure, Assessment and Monitoring:
• Day 1, 2, 3, 4 and 5: Monitor urine output and IV intake.
• Flush/Line Care per Institution standards

Hydration/Fluids:
• Day 1, 2, 3, 4 and 5: sodium chloride 0.9% IV administer 1000 mL throughout chemotherapy
 Additional additives required – these may be added to any appropriate fluid throughout treatment
 Magnesium ______ grams
 Potassium chloride ______ mEq

• Day 1 and 8: sodium chloride 0.9% IV to establish line and for flushing
 Other:



Premedications/Antiemetics: (May substitute formulary equivalent)
Day 1, 8 and 15: Give prior to bleomycin:
• acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 50 mg by mouth once
 Other:



Day 1: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *dexamethasone (Decadron) 12 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 *palonosetron (Aloxi) 0.25 mg IV once.
 *aprepitant (Emend) 125 mg by mouth once.
 fosaprepitant (Emend) 150 mg IV once.
 Other:



Day 2 and 3: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *dexamethasone (Decadron) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *aprepitant (Emend) 80 mg by mouth once.
 Other:


Day 4: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *dexamethasone (Decadron) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *palonosetron (Aloxi) 0.25 mg IV once.
 Other:


Day 5: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *dexamethasone (Decadron) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:




VER: 01-12-17 (953 VER: 12-1-16) Page 3 of 5
Copyright © 2017 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:



• bleomycin (Blenoxane) 30 units (FIXED DOSE) IV once over 15 minutes. Hypersensitivity risk. For first and
second dose, patient should be treated in a location to optimize emergency care.

• CISplatin (Platinol) ____________ mg (20 mg/m2) IV once over 60 minutes

• etoposide (Vepesid) __________ mg (100 mg/m2) IV once over 30 to 60 minutes. Administer with non-PVC
tubing.

Treatment Medications for Day 2: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• CISplatin (Platinol) ____________ mg (20 mg/m2) IV once over 60 minutes

• etoposide (Vepesid) __________ mg (100 mg/m2) IV once over 30 to 60 minutes. Administer with non-PVC
tubing.

Treatment Medications for Day 3: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• CISplatin (Platinol) ____________ mg (20 mg/m2) IV once over 60 minutes

• etoposide (Vepesid) __________ mg (100 mg/m2) IV once over 30 to 60 minutes. Administer with non-PVC
tubing.

Treatment Medications for Day 4: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• CISplatin (Platinol) ____________ mg (20 mg/m2) IV once over 60 minutes

• etoposide (Vepesid) __________ mg (100 mg/m2) IV once over 30 to 60 minutes. Administer with non-PVC
tubing.


Treatment Medications (continued on next page)

VER: 01-12-17 (953 VER: 12-1-16) Page 4 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 5: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• CISplatin (Platinol) ____________ mg (20 mg/m2) IV once over 60 minutes

• etoposide (Vepesid) __________ mg (100 mg/m2) IV once over 30 to 60 minutes. Administer with non-PVC
tubing.


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:



• bleomycin (Blenoxane) 30 units (FIXED DOSE) IV once over 15 minutes. 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:



• bleomycin (Blenoxane) 30 units (FIXED DOSE) IV once over 15 minutes. Hypersensitivity risk. For first and
second dose, patient should be treated in a location to optimize emergency care.


Conditional Orders Day 1, 2, 3, 4 and 5:
• furosemide (Lasix) 20 mg IV once as needed. Administer if intake is greater than 2000 mL and urine output
less than 500 mL.



Other Orders for Day 1, 2, 3, 4, 5, 8 and/or 15:












VER: 01-12-17 (953 VER: 12-1-16) Page 5 of 5
Copyright © 2017 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. #24, Refills: 1
Take 2 tablets (8 mg) by mouth once daily for 3 days on Day 6, 7, and 8 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.

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

Select One: (May substitute formulary equivalent)
 filgrastim (Neupogen) 300 mcg/0.5 mL syringe. Disp. 10 syringes, Refills: 6
Inject one syringe (300 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose on Day 6.

 filgrastim (Neupogen) 480 mcg/0.8 mL syringe. Disp. 10 syringes, Refills: 6
Inject one syringe (480 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose on Day 6.

 Other:


Follow Up
• Chemotherapy: Day 1, 2, 3, 4, 5, 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 #: ________