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Lung Concurrent XRT Cisplatin(28D:1,8)/Etopside(28D:1-5) (55 VER: 03-05-15)

Lung Concurrent XRT Cisplatin(28D:1,8)/Etopside(28D:1-5) (55 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 05-05-16 (55 VER: 03-05-15) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Etoposide with Concurrent XRT
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer

Therapy: CISplatin 50 mg/m2 IV Day 1 and 8,
etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5

Cycle Length: 28 days

Course: 2 cycles

NOTE: Cycle 1 starts on Day 1 = first week of radiation therapy. Cycle 2 starts on Day 29 = last week of
radiation therapy.

Reference(s): Gandara DR, et al. J Clin Oncol 2003;21:2004-10; Hanna NH, et al. J Clin Oncol 2007;
25(18S):7512.

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) _________  Day 8 (date) ________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase, Magnesium
 Other:

• Day 8: Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1 and 8: Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Day 1 and 8: Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL

Nursing Procedure, Assessment and Monitoring:
• Measure urine intake and output. If IV intake is greater than 2000 mL and urine output is less than 500 mL,
give furosemide. See Conditional Orders section.
• Flush/Line Care per Institution standards

Hydration/Fluids:
• Day 1 and 8: 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
• Day 2, 3, 4 and 5: sodium chloride 0.9% IV to establish line and for flushing

Final Approved VER: 05-05-16 (55 VER: 03-05-15) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Day 1 and 8: 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.
 *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.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:




Day 2: 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) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 aprepitant (Emend) 80 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:




Day 3: 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) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 aprepitant (Emend) 80 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:




Day 4: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *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):
 *ondansetron (Zofran) 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:



Final Approved VER: 05-05-16 (55 VER: 03-05-15) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.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:


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

• etoposide (Vepesid) ____________ mg (50 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing

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:


• etoposide (Vepsid) ____________ mg (50 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing

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:


• etoposide (Vepsid) ____________ mg (50 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing

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:


• etoposide (Vepsid) ____________ mg (50 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing

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:


• etoposide (Vepsid) ____________ mg (50 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing

Treatment Medications for Day 8: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


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


Conditional Orders for Day 1 and 8
• furosemide (Lasix) 20 mg IV once PRN. IV push rate 10 mg/minute. Administer if IV intake is greater than
2000 mL and urine output is less than 500 mL.



Final Approved VER: 05-05-16 (55 VER: 03-05-15) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Other Orders for Day 1, 2, 3, 4, 5 and/or 8:



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 on Day 9, 10, and 11.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting. Do not take on Day 1 or 8 of
each cycle.

• 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: 2
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, 2, 3, 4, 5 and 8 every 28 days (2 cycles only)

• Labs:
 Other:




• Procedures/Imaging/Scans:




• Other Orders:




MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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