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Lung Pemetrexed(21D:1) (60 VER: 03-05-15)

Lung Pemetrexed(21D:1) (60 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-17-15 (60 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Pemetrexed
Disease Group: Lung
Disease: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer
(Adjuvant/Advanced), Non-Squamous Non-Small Cell Carcinoma (Advanced – maintenance therapy), Thymic
Malignancies (Advanced)

Therapy: pemetrexed 500 mg/m2 IV Day 1,
folic acid at least 300 mcg by mouth once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed,
cyanocobalamin 1 mg IM once every 9 weeks to begin at least 1 week prior to pemetrexed and to
continue until pemetrexed is discontinued

Cycle Length: 21 days

Course: 4 to 6 cycles or until disease progression or toxicity for maintenance therapy; for Thymic Malignancies
maximum of 6 cycles

Reference(s): Scagliotti GV, et al. J Clin Oncol 2003;21:1556-61; Hanna N, et al. J Clin Oncol 2004;22:1589-97, Belani
CP, et al. J Clin Oncol 2009;27:18s:407, Loehrer PJ, et al. J Clin Oncol 2006;24:abstract #7079

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, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase
 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 1: Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Creatinine Clearance less than
45 mL/minute
• Verify that patient has taken home folic acid and dexamethasone and document. For Cycle 1 Day 1, verify that
patient received cyanocobalamin prior to first pemetrexed dose and document.

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

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







Final Approved VER: 12-17-15 (60 VER: 03-05-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics
Give prior to pemetrexed:
• dexamethasone (Decadron) 8 mg IV once PRN. For use in patients who did not take dexamethasone at home.

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.
 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:


• cyanocobalamin (Vitamin B12) 1 mg IM to be given once every 9 weeks (i.e., at least one week prior to first
dose of pemetrexed and with every 3
rd
cycle (e.g., Cycle 3, 6, 9, etc).

• pemetrexed (Alimta) __________mg (500 mg/m2) IV once over 10 minutes


Other Orders for Day 1:








Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #48, Refills: 0
Take 1 tablet (4 mg) by mouth twice daily the day prior, day of and day after chemo, then 2 tabs once daily for
2 days.

• 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:













Final Approved VER: 12-17-15 (60 VER: 03-05-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

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 #: ________