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Lung Topotecan(21D1-5) (Oral) (3247 VER: 10-03-16)

Lung Topotecan(21D1-5) (Oral) (3247 VER: 10-03-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 03-30-17 (3247 VER: 10-03-16) Page 1 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Topotecan (Oral)
Disease Group: Lung
Disease: Small Cell Lung Cancer (Adjuvant/Recurrent/Advanced)

Therapy: topotecan 2.3 mg/m2 by mouth Days 1, 2, 3, 4 and 5

Cycle Length: 21 days Course: 4 to 6 cycles

Reference(s):O’Brien ME, et al. J Clin Oncol 2006;24(34):5441-7; vonPawel J, et al. J Clin Onc 1999;17:658-67.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC
• Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL


Nursing Procedure, Assessment and Monitoring: None


Hydration/Fluids: None


Premedications/Antiemetics: None


Treatment Medications for Day 1: Refer to Take Home Medications section


Other Orders for Day 1:







Final Approved VER: 03-30-17 (3247 VER: 10-03-16) Page 2 of 2
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)
• topotecan (Hycamtin) 2.3 mg/m2 by mouth 1 time daily on Day 1 through 5. (Available capsule sizes of 1 mg
and 0.25 mg).

Take ________ mg once daily on Day 1 through 5.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth before topotecan on Day 1 through 5. May take twice daily as needed for
nausea.

 Other:





Follow Up
• Clinic Visit: Day 1 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 #: ________