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Lung Carboplatin (21D1)/Etoposide (21D1.Oral2,3) (353 VER: 03-05-15)

Lung Carboplatin (21D1)/Etoposide (21D1.Oral2,3) (353 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-29-15 (353 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carboplatin/Etoposide
Disease Group: Lung
Disease: Small Cell Lung Cancer (Adjuvant/Advanced)

Therapy: CARBOplatin (AUC = 5 to 6) IV Day 1
etoposide 100 mg/m2 IV Day 1 followed by
etoposide 100 mg/m2 by mouth twice daily Day 2 and 3

Cycle Length: 21 days Course: 4 cycles

Reference(s): Bishop JF, et al. J Clin Oncol 1987;3:1474-8.

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
• Hold and notify provider for:
 Day 1: 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
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.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:



Final Approved VER: 12-29-15 (353 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:


• CARBOplatin (Paraplatin) _____________mg (AUC = 5 to 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


• etoposide (Vepesid) ____________ mg (100 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing


Treatment Medications for Day 2 and 3:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• See Take Home Medications: etoposide

Other Orders for Day 1:










Final Approved VER: 12-29-15 (353 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)
• Etoposide (Vepesid) 50 mg cap, Disp # ________, Refills: ________

Take ________ capsules ( ________ mg (100 mg/m2)) by mouth twice daily on Day 2 and 3 of each cycle.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 3
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

• dexamethasone (Decadron) 4 mg tablet, Disp. #16, Refills: 3
Take 2 tablets (8 mg) by mouth one time daily for two days following chemotherapy.

 aprepitant (Emend) 80 mg capsule, Disp. #2, Refills: 5
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 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 #: ________