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Head-Neck Carboplatin(21D-1)/Paclitaxel(21D-1) (985 VER: 3-4-15)

Head-Neck Carboplatin(21D-1)/Paclitaxel(21D-1) (985 VER: 3-4-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 01-12-16 (985 VER: 3-4-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carboplatin/Paclitaxel
Disease Group: Head/Neck
Disease: Head and Neck Cancer (Adjuvant/Advanced)

Therapy: PACLItaxel 200 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1

Cycle Length: 21 days Course: until disease progression

Reference(s): Clark JI, et al. Cancer 2001;92:2334-40.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase, Magnesium, Glucose
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Hold and notify provider for: ANC ≤ 1500/µL or Platelets ≤ 100K/µL or Creatinine > ULN
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion
complete for the first and second dose of PACLItaxel administration. Monitor vital signs every 30 minutes for
all subsequent doses if previous doses tolerated.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to PACLItaxel:
• diphenhydramine (Benadryl) 50 mg IV once.
• ranitidine (Zantac) 50 mg IV once.
• dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take dexamethasone at
home.

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.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:


Final Approved VER: 01-12-16 (985 VER: 3-4-15) 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:




• PACLItaxel (Taxol) __________mg (200 mg/m2) in non-PVC Bag IV once through non-PVC tubing and
standard in-line filter. Administer over 180 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.


• CARBOplatin (Paraplatin) __________ mg (AUC = 6) IV once over 60 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

(GFR + 25) X AUC = Carboplatin dose (mg).

NOTE: The GFR used in this equation should not exceed 125 mL/min

Calculated Creatinine Clearance =

(140 – ___Patient age) x (patient weight in _____kg) = ________
72 x serum creatinine

(for females, multiply this result by 0.85) = ________

This value will substitute for GFR to determine Carboplatin dose

(GFR + 25) X AUC = Carboplatin dose (mg)

(_____ + 25) X ____ = Carboplatin _____________mg


Other Orders for Day 1:









Final Approved VER: 01-12-16 (985 VER: 3-4-15) 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. #48, Refills: 1
Take 5 tablets (20 mg) by mouth 12 hours and 6 hours prior to PACLItaxel dose then 2 tablets (8 mg) by
mouth once daily on Days 2, 3 and 4.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth twice daily for 2 days and every 8 hours as needed for nausea/vomiting.

 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 every 21 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 #: ________