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Lung Topotecan(21D 1-5) (351 VER: 03-05-15)

Lung Topotecan(21D 1-5) (351 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 03-24-16 (351 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Topotecan
Disease Group: Lung
Disease: Small Cell Lung Cancer (Adjuvant/Advanced)

Therapy: topotecan 1.5 mg/m2 IV Days 1, 2, 3, 4 and 5

Cycle Length: 21 days Course: 4 to 6 cycles

Reference(s): von Pawel J, et al. J Clin Onc 1999;17:658-67.

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) ___________

Pre labs:
• Day 1: 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
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/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: (May substitute formulary equivalent)
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:



Final Approved VER: 03-24-16 (351 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:


• topotecan (Hycamtin) __________mg (1.5 mg/m2) IV once over 30 minutes

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:


• topotecan (Hycamtin) __________mg (1.5 mg/m2) IV once over 30 minutes

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:


• topotecan (Hycamtin) __________mg (1.5 mg/m2) IV once over 30 minutes

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:


• topotecan (Hycamtin) __________mg (1.5 mg/m2) IV once over 30 minutes

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:


• topotecan (Hycamtin) __________mg (1.5 mg/m2) IV once over 30 minutes


Other Orders for Day 1, 2, 3, 4 and/or 5:







Final Approved VER: 03-24-16 (351 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)
• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

 Other:





Follow Up
• Chemotherapy: Day 1, 2, 3, 4, and 5 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 #: ________