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

/clinical/cckm-tools/content/ppo/name-99057-en.cckm

201608217

page

100

UWHC,UWMF,

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

GI Fluorouracil(28D:1,15)/Leucovorin(28D:1,15)/Oxaliplatin(28D:1,15) (381 VER: 04-19-13)

GI Fluorouracil(28D:1,15)/Leucovorin(28D:1,15)/Oxaliplatin(28D:1,15) (381 VER: 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 10-06-15 (381 VER: 04-19-13) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Fluorouracil/Leucovorin/Oxaliplatin (FOLFOX)
Disease Group: Gastrointestinal
Disease: Colon and Rectal Cancer (Advanced), Pancreatic Cancer (Advanced), Esophageal, GE Junction and
Gastric Cancer (Advanced), Cholangiocarcinoma (Advanced)

Therapy: oxaliplatin 85 mg/m2 IV Day 1 and 15,
leucovorin 175 - 200 mg/m2 IV Day 1 and 15,
fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours.
(Total dose = 2400 mg/m2 IV over 46 hours per home infusion) on Day 1 and 15;

Cycle Length: 28 days

Course: 6 cycles (total of 12 doses for adjuvant) or until disease progression for advanced

Reference(s): Andre T, et al. N Engl J Med 2004;350(23):2343-51, Ducreux M, et al. Ann Oncol 2004;15(3):467-
73, Tsavaris N, et al. Invest New Drugs 2005;23(4):369-75, Cavanna L, et al. Am J Clin Oncol 2006;29(4):371-5,
Mauer AM, et al. Ann Oncol 2005;16(8):1320-5, Lim JY, et al. Anticancer Drugs 2008;19(6):631-5.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase,
 Other:


• Day 15: Obtain CBC without DIFF, ANC
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1 and 15: Verify the following labs have been obtained: WBC, ANC, Platelets
• Hold and notify provider for:
 Day 1 and 15: ANC ≤ 1000/µL or Platelets ≤ 75K/µL
• Day 1 and 15: Check for mucositis, irritation of hands or feet, or diarrhea.

Nursing Procedure, Assessment and Monitoring:
• Educate/reinforce with patient regarding hand and foot syndrome related to continuous fluorouracil infusion
and to call with concerns.
• Educate/reinforce with patient regarding “cold neuropathy” that occurs with oxaliplatin
• Flush/Line Care per Institution standards
• Disconnect pump upon completion of 46-hour fluorouracil infusion. on Day 3 and 17
 In Clinic  At Home By Patient  At Home by Home Health Nurse  Other _______________

Final Approved VER: 10-06-15 (381 VER: 04-19-13) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Hydration/Fluids:
• Dextrose 5% in Water IV to establish line and for flushing

Premedications/Antiemetics
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:

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 (85 mg/m2) IV once over 120 minutes.
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment medications.

• leucovorin ____________ mg (_______ mg/m2, Dose = 175-200 mg/m2) IV once over 120 minutes
Leucovorin may be administered (via separate lines) concurrently with oxaliplatin.

• fluorouracil (Adrucil) ____________ mg (400 mg/m2) IV bolus once over 5 to 15 minutes

• fluorouracil (Adrucil) ____________ mg (2400 mg/m2) continuous IV infusion over 46 hours


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:


• oxaliplatin (Eloxatin) __________mg (85 mg/m2) IV once over 120 minutes.
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment medications.

• leucovorin ____________ mg (_______ mg/m2, Dose = 175-200 mg/m2) IV once over 120 minutes
Leucovorin may be administered (via separate lines) concurrently with oxaliplatin.

• fluorouracil (Adrucil) ____________ mg (400 mg/m2) IV bolus once over 5 to 15 minutes

• fluorouracil (Adrucil) ____________ mg (2400 mg/m2) continuous IV infusion over 46 hours




Final Approved VER: 10-06-15 (381 VER: 04-19-13) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Other Orders for Day 1 and/or 15:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #24, Refills: 5
Take 2 tablets (8 mg) by mouth once daily for 3 days following 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.

 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 and 15 every 28 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 #: ________