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GYN Liposomal Doxorubicin(28D:1)(389 VER: 08-19-13)

GYN Liposomal Doxorubicin(28D:1)(389 VER: 08-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 02-24-16 (389 VER: 08-19-13) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Liposomal Doxorubicin
Disease Group: Gynecology/Oncology
Disease: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced)

Therapy: LIPOSOMAL doxorubicin 50 mg/m2 IV Day 1

Cycle Length: 28 days Course: until disease progression

Reference(s): Gordon AN, et al. J Clin Oncol 2001;19:3312-22

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, CA-125 (for ovarian cancer only), Magnesium,
BUN, Creatinine
 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 ≤ 100K/µL

Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored every 15 minutes for the first and second dose of LIPOSOMAL doxorubicin and
then every 30 minutes for any subsequent doses.
• Educate patient about hand-foot syndrome and mucositis.
• Flush/Line Care per Institution standards

Hydration/Fluids:
• sodium chloride 0.9% IV administer 1000 mL over 1 to 2 hours before LIPOSOMAL doxorubicin to decrease
the incidence of hand-foot syndrome. Flush line with D5W before and after infusion of LIPOSOMAL
doxorubicin (incompatible with NS)
• dextrose 5% in water IV to establish line and for flushing. Flush line with 50 mL D5W before and after infusion
of LIPOSOMAL doxorubicin (incompatible with NS).

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: 02-24-16 (389 VER: 08-19-13) Page 2 of 2
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:


• LIPOSOMAL doxorubicin (Doxil) __________mg (50 mg/m2) IV once. Administer first dose at 50 mL/hour for
15 minutes; if tolerated increase to 100 mL/hour for 15 minutes. If tolerated increase to final rate over 60
minutes. Subsequent doses may be administered over 60 minutes. Hypersensitivity risk. For first and second
dose, patient should be treated in a location to optimize emergency care.

Other Orders for Day 1:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

 Other:



Follow Up
• Chemotherapy: Day 1 every 28 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 #: ________