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Lung Carboplatin(21D1)/Gemcitabine(21D1,8) 151202F (56 VER: 03-05-15)

Lung Carboplatin(21D1)/Gemcitabine(21D1,8) 151202F (56 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-2-15 (56 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carboplatin/Gemcitabine
Disease Group: Lung
Disease: Non-small Cell Lung Cancer (Adjuvant/Advanced)

Therapy: gemcitabine 1250 mg/m2 IV Day 1 and 8,
CARBOplatin (AUC=5) IV Day 1

Cycle Length: 21 days Course: 4 to 6 cycles

Reference(s): Sederholm C, et al. J Clin Onc 2005;23:8380-88.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 8 (date) ___________

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


• Day 8: Obtain CBC without DIFF, ANC
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Day 8: Verify the following labs have been obtained: WBC, ANC, Platelets
• Day 1: Hold and notify provider for: ANC ≤ 1500/µL or Platelets ≤ 75K/µL

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 for Day 1:
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) 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:

Premedications/Antiemetics for Day 8:
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: 12-2-15 (56 VER: 03-05-15) Page 2 of 3
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:


• gemcitabine (Gemzar) __________ mg (1250 mg/m2) IV once over 30 minutes. Additional sodium chloride
0.9% may be y-set into IV site to decrease site irritation.

• CARBOplatin (Paraplatin) __________ mg (target dose AUC=5) IV once over 60 minutes


(GFR + 25) X AUC = CARBOplatin dose (mg).

NOTE: The GFR used in this equation should not exceed 125 mL/min

Calculated Creatinine Clearance =

(140 – ___Patient age) x (patient weight in _____kg) = ________
72 x serum creatinine

(for females, multiply this result by 0.85) = ________

This value will substitute for GFR to determine CARBOplatin dose

(GFR + 25) X AUC = CARBOplatin dose (mg)

(_____ + 25) X ____ = CARBOplatin _____________ mg

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:


• gemcitabine (Gemzar) __________ mg (1250 mg/m2) IV once over 30 minutes. Additional sodium chloride
0.9% may be y-set into IV site to decrease site irritation.

Other Orders for Day 1 and/or 8:



Final Approved VER: 12-2-15 (56 VER: 03-05-15) Page 3 of 3
Copyright © 2016 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. #24, Refills: 5
Take 2 tablets (8 mg) by mouth for 3 days following carboplatin.

• 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 and 8 every 21 days

• Labs:
 Day 15 – 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 #: ________