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Hem Decitabine(28D:1-5) (1516 VER: 10-3-16)

Hem Decitabine(28D:1-5) (1516 VER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 11-2-17 (1516 VER: 10-3-16) Page 1 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Decitabine
Disease Group: Hematology
Disease: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia,
Myelodysplastic Syndrome

Therapy: decitabine 20 mg/m2 IV Day 1 through 5,

Cycle Length: 28 days Course: minimum of 3 cycles to determine response or failure

Reference(s): Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8; Ravandi F, et al. Cancer
2009;115(24):5746-51; Kantarjian H, et al. Blood 2007;109(1):52-7; Cashen AF, et al. J Clin Oncol
2010;28(4):556-61

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 with DIFF, Creatinine, Total Bilirubin, ALT
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
• Day 1: Hold and notify provider for: ANC < 500/µL or Platelets < 50K/µL or Creatinine ≥ 2 mg/dL or Total
Bilirubin ≥ 2.8 mg/dL or ALT ≥ 2 X ULN

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

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

Premedications/Antiemetics: none (May substitute formulary equivalent)
 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:

• decitabine (Dacogen) __________mg (20 mg/m2) IV once over 60 minutes


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:

• decitabine (Dacogen) __________mg (20 mg/m2) IV once over 60 minutes

Treatment Medications (continued on next page)

VER: 11-2-17 (1516 VER: 10-3-16) Page 2 of 2
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:

• decitabine (Dacogen) __________mg (20 mg/m2) IV once over 60 minutes

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:

• decitabine (Dacogen) __________mg (20 mg/m2) IV once over 60 minutes

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:

• decitabine (Dacogen) __________mg (20 mg/m2) IV once over 60 minutes

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)
• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth two times daily.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

 Other:

Follow Up
• Chemotherapy: Day 1, 2, 3, 4 and 5 every 28 days

• Labs: Day 8, 11, 15, 18, 22 and 25 – Obtain CBC with DIFF
 Other:

• Procedures/Imaging/Scans:


• Other Orders:


MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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