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Lung Alectinib28D1-28 (5969 VER: 10-3-16)

Lung Alectinib28D1-28 (5969 VER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 6-15-17 (5969 VER: 10-3-16) Page 1 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Alectinib
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Advanced)

Therapy: alectinib 600 mg by mouth twice daily continuously

Cycle Length: 28 days Course: until disease progression

Note to All Staff: Chemotherapy Council approved for NSCLC patients harboring anaplastic lymphoma kinase
(ALK)-positive gene arrangement and who have failed or are intolerant to crizotinib.

Reference(s): Gandhi L, et al. J Clin Oncol 2015;33(Suppl. 15):8019; Ou S, et al. J Clin Oncol
2015;33(10.1200/JCO.2015.63.9443)

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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


Pre labs:
• Obtain Total Bilirubin, AST, ALT, Total CK
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: Total Bilirubin, AST, ALT, Total CK
• Hold and notify provider for: AST > 3 x ULN or ALT > 3 x UNL or Total Bilirubin > 3 x UNL or Total CK > 5 x
ULN

Nursing Procedure, Assessment and Monitoring: Flush/Line Care per Institution standards

Hydration/Fluids: None

Premedications/Antiemetics: None

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:


• See Take Home Medication section

Other Orders for Day 1




VER: 6-15-17 (5969 VER: 10-3-16) 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)
• alectinib (Alecensa) 150 mg capsule, Disp. #240, Refills: ______
Take 4 capsules (600 mg) by mouth two times daily at mealtime.

 Other:



Follow Up
• Chemotherapy: Day 1 every 28 days

• Labs:
 Cycle 1, Day 15 – Obtain Total Bilirubin, AST, ALT, Total CK
 Cycle 2, Day 15 – Obtain Total Bilirubin, AST, ALT

 Other:



• Procedures/Imaging/Scans:














• Other Orders:








MD Signature_________________________________________ Pager______________
Date __________________Time___________________

Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________