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

/clinical/cckm-tools/content/ppo/name-99045-en.cckm

201608217

page

100

UWHC,UWMF,

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

Lung Bevacizumab(21D1)/Carboplatin(21D1)/Paclitaxel(21D1) (333 VER: 03-05-15)

Lung Bevacizumab(21D1)/Carboplatin(21D1)/Paclitaxel(21D1) (333 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 04-06-16 (333 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bevacizumab/Carboplatin/Paclitaxel
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Advanced)

Therapy: PACLItaxel 200 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1,
bevacizumab 15 mg/kg IV Day 1,

Cycle Length: 21 days Course: 4 to 6 cycles

NOTE: May be followed by bevacizumab 15 mg/kg IV Day 1 every 21 days at the discretion of authorizing
prescriber. See separate order set.

Reference(s): Sandler AB, et al. Proc Am Soc Clin Oncol 2005;Abs LBA4

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, Urinalysis (no microscopy)
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine, Urine Protein
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Urine Protein ≥ 100 mg/dL or Blood
Pressure ≥ 160/90 mmHg
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored 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.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to paclitaxel:
• dexamethasone (Decadron) 20 mg IV once PRN. For use in patients who did not take dexamethasone at
home.
• diphenhydramine (Benadryl) 50 mg IV once
• ranitidine (Zantac) 50 mg IV once


Final Approved VER: 04-06-16 (333 VER: 03-05-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics (cont.): (May substitute formulary equivalent)
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.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth 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 (200 mg/m2) IV once over 180 minutes. Use non-PVC tubing and 0.22
micron in-line filter during administration.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• CARBOplatin (Paraplatin) __________ mg (AUC = 6) IV once over 60 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

(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

• bevacizumab (Avastin) ____________ mg (15 mg/kg) IV once. Administer first dose over 90 minutes. If
tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. If infusion-related reactions occur, all subsequent infusions should be administered over
the shortest period that was well tolerated


Final Approved VER: 04-06-16 (333 VER: 03-05-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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. #50, Refills: 1
Take 5 tablets (20 mg) by mouth 12 and 6 hours prior to each PACLItaxel dose and 2 tablets (8 mg) once daily
for 3 days after chemotherapy.

• 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 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 #: ________