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Breast Trastuzumab(42D:1, 22) (671 VER: 2-18-15)

Breast Trastuzumab(42D:1, 22) (671 VER: 2-18-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 08-26-15 (671 VER: 2-18-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Trastuzumab
Disease Group: Breast
Disease: Breast Cancer (Adjuvant/Advanced)

Therapy:
Cycle 1:
trastuzumab 8 mg/kg IV Loading Dose Day 1
trastuzumab 6 mg/kg IV Day 22
Cycles ≥ 2:
trastuzumab 6 mg/kg IV Days 1 and 22

Cycle Length: 42 days Course: 9 cycles (one year of therapy = 18 doses) for adjuvant or until
disease progression for advanced.

Reference(s): Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 22 (date) ___________

Pre labs:
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.

Nursing Procedure, Assessment and Monitoring:
• Flush/Line Care per Institution standards

Hydration/Fluids:
• Day 1 and Day 22: sodium chloride 0.9% IV to establish line and for flushing

Premedications/Antiemetics: None

Treatment Medications:
• trastuzumab (Herceptin) __________mg (8 mg/kg – CYCLE 1, DAY 1 ONLY) IV once over 90 minutes
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. Patients must be monitored for one hour after the first dose of trastuzumab.
• trastuzumab (Herceptin) __________mg (6 mg/kg) IV Day 1 once over 30 minutes
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.
• trastuzumab (Herceptin) __________mg (6 mg/kg) IV Day 22 once over 30 minutes
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

Final Approved VER: 08-26-15 (671 VER: 2-18-15) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Other Orders Day 1 and/or Day 22:




Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
 Other:


Follow Up
• Chemotherapy: Day 1 and 22 every 42 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 #: ________