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GI Cetuximab(21D:1,8,15) (371 VER: 07-21-15)

GI Cetuximab(21D:1,8,15) (371 VER: 07-21-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders



Final Approved VER: 10-22-15 (371 VER: 07-21-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cetuximab
Disease Group: Gastrointestinal
Disease: Colon and Rectal Cancer (Advanced)

Therapy: cetuximab 400 mg/m2 (loading dose) IV Day 1, Cycle 1 only followed by
cetuximab 250 mg/m2 IV once weekly

Cycle Length: 21 days Course: 6 cycles

Note: Chemotherapy Council approved only for patients who do not tolerate panitumumab

Reference(s): Saltz L, et al. J Clin Oncol 2004;22:1201-8

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 15 (date) ___________

Pre labs:
• Day 1: Magnesium, Carcinoembryonic Antigen (CEA)
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Hold and notify provider for any pre-lab results not within normal limits

Nursing Procedure, Assessment and Monitoring:
• Cycle 1, Day 1 and 8: Vital Signs to be monitored every 15 minutes for the first hour and then every 30
minutes until cetuximab infusion is complete. Nurse should remain with patient for the first 15 minutes of drug
administration for the first and second dose of cetuximab administration.
• Cycle 1, Day 15 and Cycles 2+: Vital signs to be monitored every 30 minutes for the first hour until cetuximab
infusion complete if first and second administration without hypersensitivity reaction. If history of
hypersensitivity reaction, increase vital sign monitoring and frequency of nursing assessment.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics
Give prior to cetuximab:
• Acetaminophen 650 mg by mouth once.
• Diphenhydramine 50 mg IV once




Final Approved VER: 10-22-15 (371 VER: 07-21-15) 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:


Cycle 1:
• cetuximab (Erbitux) ___________mg (400 mg/m2) IV once over 120 minutes through 0.22 micron in-line filter.
Do not dilute. Maximum rate 5 mL/minute.
o Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must remain in treatment area for 60 minutes following the completion of the
first dose.

Cycle 2+:
• cetuximab (Erbitux) ____________ mg (250 mg/m2) IV once over 60 minutes (if tolerated from previous dose)
through 0.22 micron in-line filter. Do not dilute. Maximum rate 5 mL/minute.
o Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

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:


• cetuximab (Erbitux) ____________ mg (250 mg/m2) IV once over 60 minutes (if tolerated from previous dose)
through 0.22 micron in-line filter. Do not dilute. Maximum rate 5 mL/minute.
o Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

Treatment Medications for Day 15: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• cetuximab (Erbitux) ____________ mg (250 mg/m2) IV once over 60 minutes (if tolerated from previous dose)
through 0.22 micron in-line filter. Do not dilute. Maximum rate 5 mL/minute.
o Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

Other Orders for Day 1, 8 and/or 15:













Final Approved VER: 10-22-15 (371 VER: 07-21-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications
 Other:




Follow Up
• Chemotherapy: Day 1, 8, and 15 every 21 days

• Labs:
 Other:




• Procedures/Imaging/Scans:












• Other Orders:








MD Signature_________________________________________ Pager______________
Date __________________Time___________________


Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________