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GI Concurrent XRT Fluorouracil(28D1-4) Mitomycin(28D1) (562 V ER: 10-3-16)

GI Concurrent XRT Fluorouracil(28D1-4) Mitomycin(28D1) (562 V ER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 04-13-17 (562 V ER: 10-3-16) Page 1 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uw health.org
Title: Concurrent XRT Fluorouracil/Mitomycin
Disease Group: Gastrointestinal
Disease: Anal Cancer (Adjuvant)

Therapy: mitomycin 10 mg/m2 IV Day 1,
fluorouracil 1000 mg/m2/DAY administered as a continuous infusion Day 1 through 4
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion)

Cycle Length: 28 days Course: 2 cycles

Reference(s): Ajani JA, et al. J Clin Oncol 2006;24:4009.

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, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
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 ≤ 75K/µL
• Check for mucositis, irritation of hands or feet, or diarrhea.

Nursing Procedure, Assessment and Monitoring:
• Educate/reinforce with patient regarding hand and foot syndrome related to fluorouracil and to call with
concerns.
• Flush/Line Care per Institution standards
• Disconnect pump upon completion of 96-hour fluorouracil infusion on Day 5
 In Clinic  At Home By Patient  At Home by Home Health Nurse  Other _______________

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

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:



VER: 04-13-17 (562 V ER: 10-3-16) Page 2 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uw health.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:


• mitomycin (Mutamycin) __________mg (10 mg/m2) IV once over 5 to 10 minutes side arm push. **Vesicant**

• fluorouracil (Adrucil) ____________ mg (4000 mg/m2) continuous IV infusion over 96 hours

Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #12, 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: 5 -
Take 1 capsule by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

Follow Up
• Chemotherapy: Day 1 every 28 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 #: ________