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GI Concurrent XRT Capecitabine (35D1-5) (524 VER: 04-19-13)

GI Concurrent XRT Capecitabine (35D1-5) (524 VER: 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 10-1-15 (524 VER: 04-19-13) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Capecitabine with Concurrent XRT
Disease Group: Gastrointestinal
Disease: Gastric (Adjuvant/Advanced), Pancreatic (Adjuvant/Advanced), Esophageal (Adjuvant/Advanced),
Rectal (Adjuvant/Advanced), Anal (Adjuvant/Advanced), Cholangiocarcinoma (Advanced),
Gall Bladder (Adjuvant/Advanced)

Therapy: capecitabine 825 mg/m2 by mouth twice daily for 5 days/week, concurrent with radiotherapy

Cycle Length: 35 days Course: for duration of radiotherapy

Reference(s): Saif M, et al. J Clin Oncol 2005;23:8679-87; Rich TA, et al. J Clin Oncol 2004;22:2214-32

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• 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 or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Educate/reinforce with patient regarding hand and foot syndrome with capecitabine and to call with concerns.
• Flush/Line Care per Institution standards

Hydration/Fluids: none

Premedications/Antiemetics: none

Treatment Medications for Day 1: see Take Home Medication Section

Other Orders for Day 1:











Final Approved VER: 10-1-15 (524 VER: 04-19-13) Page 2 of 2
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)
• capecitabine (Xeloda) 825 mg/m2 by mouth 2 times daily. Disp. #_____, Refills: 0
(Round dose to available tablet sizes of 500 mg and 150 mg.)

Take _____ mg in AM and _____ mg in PM on Monday through Friday for duration of radiotherapy (10 doses
weekly).

• 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
• Clinic: Post-chemotherapy radiation appointment with provider

• Labs: CBC, ANC (DIFF if done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase
 Other:


• Procedures/Imaging/Scans:











• Other Orders:



MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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