/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/ppo/,

/clinical/cckm-tools/content/ppo/name-123628-en.cckm

201712353

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Preprinted Paper Orders

GYN Cisplatin(21D:1)/Paclitaxel(21D:1) (5365 VER: 01-11-17)

GYN Cisplatin(21D:1)/Paclitaxel(21D:1) (5365 VER: 01-11-17) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 12-19-17 (5365 VER: 01-11-17) Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Paclitaxel
Disease Group: Gynecology/Oncology
Disease: Cervical, Vaginal, Vulvar Cancer (Advanced)

Therapy: PACLItaxel 135 to 175 mg/m2 IV Day 1,
CISplatin 50 mg/m2 IV Day 1,

Cycle Length: 21 days Course: until disease progression

Reference(s): Moore DH, et al. J Clin Oncol 2004;22(15):3113-9; Tewari K, et al. N Engl Med 2014;370(8):734-
43.

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, Calcium, Albumin, Total
Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin
• Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL or Creatinine > ULN or Total Bilirubin > 1.6
mg/dL or AST > 5 X ULN
• Cycles 1, 2 and 3: Verify that patient has taken home dexamethasone and document.


Nursing Procedure, Assessment and Monitoring:
• Monitor vital signs every 15 minutes for the first hour and then every 30 minutes until infusion complete for the
first and second dose of PACLItaxel administration. Monitor vital signs every 30 minutes for all subsequent
doses if previous doses tolerated.
• Measure urine output. Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
• Flush/Line Care per Institution standards


Hydration/Fluids: sodium chloride 0.9% with potassium chloride 20 mEq/L IV administer 1000 mL over 1 hour
prior to starting CISplatin infusion.



VER: 12-19-17 (5365 VER: 01-11-17) Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to PACLItaxel:
• diphenhydramine (Benadryl) 50 mg IV once
• famotidine (Pepcid) 20 mg IV once
• Cycles 1, 2 and 3: dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
• Cycles 4+: dexamethasone (Decadron) 10 mg IV once.

Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 24 mg by mouth once. PO preferred – may give 12 mg IV if unable to tolerate PO.
 *aprepitant (Emend) 125 mg by mouth once.
 fosaprepitant (Emend) 150 mg IV once.
 palonosetron (Aloxi) 0.25 mg IV once.
 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:


• PACLItaxel (Taxol) __________mg (_______mg/m2 (range 135 to 175 mg/m2) in non-PVC Bag IV once
through non-PVC tubing and standard in-line filter. Administer over 180 minutes (see titration instructions
below). Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. For first dose or if patient reacted to previous dose: 50 mL/hr for 3 to 5 min, 100 mL/hr for 3
to 5 min, 150 mL/hr for 3 to 5 min, then max rate for the remainder. RN to remain at bedside for additional 3 to
5 minutes. If patient did not react to 1
st
or subsequent doses, administer volume of bag over ordered duration.

• CISplatin (Platinol) ____________ mg (50 mg/m2) IV once over 60 to 90 minutes



Other Orders for Day 1:




VER: 12-19-17 (5365 VER: 01-11-17) Page 3 of 3
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)
• dexamethasone (Decadron) 4 mg tablet, Disp. #56, Refills: 0
Take 5 tablets (20 mg) by mouth 12 hours and 6 hours before 1
st
PACLItaxel dose and 3 tablets (12 mg) by
mouth 12 hours and 6 hours before 2
nd
PACLItaxel dose and 2 tablets (8 mg) by mouth 12 hours and 6 hours
before 3
rd
PACLItaxel dose. In addition, take 2 tablets (8 mg) by mouth once daily for 3 days after each
CISplatin dose.

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

• 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)

 Other:


Follow Up
• Chemotherapy: Day 1 every 21 days

• Labs:
 Day 10 – 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 #: ________