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

/clinical/cckm-tools/content/ppo/name-99071-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)/Irinotecan(28D:1,15) (422 VER: 07-24-15)

GI Fluorouracil(28D:1,15)/Leucovorin(28D:1,15)/Irinotecan(28D:1,15) (422 VER: 07-24-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 10-06-16 (422 VER: 07-24-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Fluorouracil/Irinotecan/Leucovorin (FOLFIRI)
Disease Group: Gastrointestinal
Disease: Colon and Rectal Cancer (Advanced)

Therapy: irinotecan 180 mg/m2 IV Day 1 and 15,
leucovorin 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
Reference(s): Andre, et al. Eur J Cancer 1999;35:1343-7; Tournigand, et al. J Clin Oncol 2004;23:229-37

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• NOTE: it is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the
start of irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Carcinoembryonic Antigen (CEA)
 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

Nursing Procedure, Assessment and Monitoring:
• Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea,
diaphoresis, weakness)
• 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 _______________

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



Final Approved VER: 10-06-16 (422 VER: 07-24-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:


• irinotecan (Camptosar) __________mg (180 mg/m2) IV once over 90 minutes

• leucovorin ____________ mg (200 mg/m2) IV once over 120 minutes
Leucovorin may be administered (via separate lines) concurrently with irinotecan.

• 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:


• irinotecan (Camptosar) __________mg (180 mg/m2) IV once over 90 minutes

• leucovorin ____________ mg (200 mg/m2) IV once over 120 minutes
Leucovorin may be administered (via separate lines) concurrently with irinotecan.

• 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


Conditional Orders Day 1 and 15:
• atropine 0.3 mg subcutaneous PRN for irinotecan cholinergic side effects. May repeat every 30 minutes PRN
for a total of 3 doses. Total allowed dose = 0.9 mg.

Other Orders for Day 1 and/or 15:






Final Approved VER: 10-06-16 (422 VER: 07-24-15) 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)
• 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.

• loperamide (Imodium) 2 mg tablet, Disp. Available OTC
Take 2 tablets (4 mg) by mouth with 1
st
loose stool followed by 1 tab every 2 hours or 2 tablets every 4 hours
until no diarrhea for 12 hours. Max dose = 8 tablets/day

 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 #: ________