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GU Cisplatin(21D1-5)-Ifosfamide(21D1-5)-Vinblastine(21D1,2) (VeIP) (842 VER: 12-1-16)

GU Cisplatin(21D1-5)-Ifosfamide(21D1-5)-Vinblastine(21D1,2) (VeIP) (842 VER: 12-1-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 6-27-17 (842 V ER: 12-1-16) Page 1 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uw health.org
Title: Cisplatin/Ifosfamide/Vinblastine (VeIP)
Disease Group: Genitourinary
Disease: Testicular, Germ Cell Cancer (Advanced)

Therapy: mesna 1200 mg/m2 IV Day 1 through 5 given as 400 mg/m2 IV prior to the start of ifosfamide and 4
and 8 hours after the start of ifosfamide,
ifosfamide 1200 mg/m2 IV Day 1 through 5,
CISplatin 20 mg/m2 IV Day 1 through 5,
vinBLAStine 0.11 mg/kg IV Days 1 and 2

Cycle Length: 21 days Course: 4 cycles

Reference(s): Loehrer PJ, et al. J Clin Oncol 1998;16:2500-4; Motzer RJ, et al. Cancer 1991:67:1305-10

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) _________  Day 2 (date) _________  Day 3 (date) __________
 Day 4 (date) _________  Day 5 (date) _________
Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Magnesium, Potassium, Creatinine, Urinalysis without Microscopy,
Alpha-Fetoprotein, Quantitative HCG, LDH
 Other:

• Day 2 and 3: Urinalysis without Microscopy
 Other:

• Day 4: Magnesium, Potassium, Creatinine, Phosphate, Urinalysis without Microscopy
 Other:

• Day 5: Urinalysis without Microscopy
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1: WBC, ANC, Platelets, Creatinine, Magnesium, Urine Heme
 Day 2, 3, 4 and 5: Urine Heme
• Hold and notify provider for:
 Day 1: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Urine Hemoglobin > Trace or Creatinine > ULN
 Day 2, 3, 4 and 5: Urine Hemoglobin > Trace

Nursing Procedure, Assessment and Monitoring:
• Monitor urine output and IV intake. If intake is > 2000 mL and urine output < 500 mL, administer furosemide –
see Conditional Orders.
• Flush/Line Care per Institution standards



VER: 6-27-17 (842 V ER: 12-1-16) Page 2 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uw health.org
Hydration/Fluids: 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

Premedications/Antiemetics: (May substitute formulary equivalent)
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.
 *fosaprepitant (Emend) 150 mg IV once.
 *palonosetron (Aloxi) 0.25 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 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:


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:


• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes prior to ifosfamide

• ifosfamide (Ifex) ____________ mg (1200 mg/m2) IV once over 60 minutes

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

• vinBLAStine (Velban) ____________ mg (0.11 mg/kg) IV once over 5 minutes

• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes at 4 hours and 8 hours after the start
of ifosfamide.


Treatment Medications (continued on next page)

VER: 6-27-17 (842 V ER: 12-1-16) Page 3 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uw health.org
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:


• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes prior to ifosfamide

• ifosfamide (Ifex) ____________ mg (1200 mg/m2) IV once over 60 minutes

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

• vinBLAStine (Velban) ____________ mg (0.11 mg/kg) IV once over 5 minutes

• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes at 4 hours and 8 hours after the start
of ifosfamide.


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:


• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes prior to ifosfamide

• ifosfamide (Ifex) ____________ mg (1200 mg/m2) IV once over 60 minutes

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

• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes at 4 hours and 8 hours after the start
of ifosfamide.

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:


• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes prior to ifosfamide

• ifosfamide (Ifex) ____________ mg (1200 mg/m2) IV once over 60 minutes

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

• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes at 4 hours and 8 hours after the start
of ifosfamide.


Treatment Medications (continued on next page)



VER: 6-27-17 (842 V ER: 12-1-16) Page 4 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uw health.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:


• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes prior to ifosfamide

• ifosfamide (Ifex) ____________ mg (1200 mg/m2) IV once over 60 minutes

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

• mesna (Mesnex) __________mg (400 mg/m2) IV once over 10 minutes at 4 hours and 8 hours after the start
of ifosfamide.

Conditional Orders Day 1, 2, 3, 4 and 5
• furosemide 20 mg IV once PRN. Administer if intake is > 2000 mL and urine output < 500 mL.

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







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 on Day 6, 7 and 8

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 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)

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. Begin Day 6 and continue until ANC is
greater than ___________ after nadir.

 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. Begin Day 6 and continue until ANC is
greater than ___________ after nadir.

 Other:




VER: 6-27-17 (842 V ER: 12-1-16) Page 5 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uw health.org
Follow Up
• Chemotherapy: Day 1, 2, 3, 4 and 5 every 28 days

• Labs: Day 10 – Obtain CBC, ANC (DIFF if done locally)
 Cycle 1 only:
 Day 8 – Obtain Alpha-Fetoprotein, Quantitative HCG, LDH per MD discretion
 Day 15 – Obtain Alpha-Fetoprotein, Quantitative HCG, LDH per MD discretion
 Other:




• Procedures/Imaging/Scans:
















• Other Orders:














MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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