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GI Capecitabine(21D:1-15 ORAL)/Oxaliplatin(21D:1) (376 VER: 04-19-13)

GI Capecitabine(21D:1-15 ORAL)/Oxaliplatin(21D:1) (376 VER: 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 01-28-16 (376 VER: 04-19-13) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Capecitabine/Oxaliplatin
Disease Group: Gastrointestinal
Disease: Colon and Rectal Cancer (Adjuvant/Advanced), Esophagus, GE Junction, Gastric Cancer (Advanced)

Therapy: oxaliplatin 130 mg/m2 IV Day 1,
capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 15

Cycle Length: 21 days Course: 3 cycles

Reference(s): Scheithauer W, et al. J Clin Oncol 2003;21:1307-12, Jatoi A, et al. Ann Oncol 2006;17(1):29-34.

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, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: WBC, ANC, Platelets
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL
• Cycle 2+: Verify that patient has taken capecitabine and document.

Nursing Procedure, Assessment and Monitoring:
• Educate/reinforce with patient oxaliplatin neuropathy exacerbated by cold.
• Educate/reinforce with patient regarding hand and foot syndrome with capecitabine and to call with concerns.
• Check for mucositis, irritation of hands or feet, or diarrhea.
• Flush/Line Care per Institution standards

Hydration/Fluids: dextrose 5% in water IV to establish line and for flushing

Premedications/Antiemetics: (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.
 *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: 01-28-16 (376 VER: 04-19-13) 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:


• oxaliplatin (Eloxatin) __________ mg (130 mg/m2) IV once over 120 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. NOTE: Incompatible with sodium chloride.


• capecitabine (Xeloda) – refer to Take Home Medications section


Other Orders for Day 1:





Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• capecitabine (Xeloda) 1000 mg/m2 by mouth 2 times daily for 14 days. (Round dose to available tablet sizes
of 500 mg and 150 mg.)

Take _______ mg in AM and ________ mg in PM daily beginning evening of ____________ (date) through
morning of ____________ (date).

• dexamethasone (Decadron) 4 mg tablet, Disp. #24, Refills: 5
Take 2 tablets (8 mg) by mouth for 3 days following oxaliplatin.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

 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:





Final Approved VER: 01-28-16 (376 VER: 04-19-13) 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:
 Other:





• Procedures/Imaging/Scans:












• Other Orders:











MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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