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GI Panitumumab (28D:1,15) (410 VER: 07-21-15)

GI Panitumumab (28D:1,15) (410 VER: 07-21-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved 1-06-16 (410 VER: 07-21-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Panitumumab
Disease Group: Gastrointestinal
Disease: Colon Cancer (Advanced)

Therapy: panitumumab 6 mg/kg IV Day 1 and 15

Cycle Length: 28 days Course: 6 cycles

Reference(s): Wasif SM, et al. Clinical Colorectal Cancer 2006;6(2):118-124


Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain Calcium, Magnesium, Phosphate
 Other:


• Day 15: Obtain Calcium, Magnesium, Phosphate
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1 and 15: Verify the following labs have been obtained: Calcium, Magnesium, Phosphate
• May proceed with treatment and notify provider of any abnormalities in Calcium, Magnesium, Phosphate.

Nursing Procedure, Assessment and Monitoring:
• Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use
sunscreen, wear hats) and to contact provider if rash or other skin reaction occurs.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics: None
 Other:




Final Approved 1-06-16 (410 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:


• panitumumab (Vectibix) __________mg (6 mg/kg) IV once over 60 minutes. Administer through low protein
binding tubing and 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50 mL after infusion complete.
Doses greater than 1000 mg should be administered over 90 minutes.
Hypersensitivity reaction can occur. 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:


• panitumumab (Vectibix) __________mg (6 mg/kg) IV once over 60 minutes. Administer through low protein
binding tubing and 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50 mL after infusion complete.
Doses greater than 1000 mg should be administered over 90 minutes.
Hypersensitivity reaction can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.


Other Orders for Day 1 and/or 15:







Final Approved 1-06-16 (410 VER: 07-21-15) 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)
• doxycycline 100 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (100 mg) by mouth twice daily with food.

 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 #: ________