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HEM Azacitidine IV or Subcutaneous (28D:1-7) (1519 VER: 11-23-15)

HEM Azacitidine IV or Subcutaneous (28D:1-7) (1519 VER: 11-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 03-02-16 (1519 VER: 11-23-15) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Azacitidine
Disease Group: Hematology
Disease: Myelodysplastic Syndrome, Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia

Therapy: azacitidine 75 mg/m2 IV or subcutaneous Days 1 through 7. If no response after 2 cycles, may
increase azacitidine to 100mg/m2 IV or subcutaneous Days 1 through 7

Cycle Length: 28 days Course: minimum 4 to 6 cycles to determine response or failure.

Reference(s): Silverman LR, et al. J Clin Oncol 2006;24(24):3895-903, Dombret H, et al. Blood 2015;
126(3):291-9, Fenaux P, et al. Lancet Oncol 2009;10(3):223-32, Fenaux P, et al. J Clin Oncol 2010;28(4):562-9

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 2 (date) ___________  Day 3 (date) _______
 Day 4 (date) __________  Day 5 (date) ___________  Day 6 (date) ___________  Day 7 (date) _______

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin,
Total Bilirubin, AST, Alkaline Phosphatase
• Day 1: Hold and notify provider for: ANC less than 500/µL or Platelets less than 50K/µL or Carbon Dioxide less
than 20 mmol/L or BUN greater than 20 mg/dL or Creatinine greater than 1.3 mg/dL or Albumin less than 3
gm/dL or Total Bilirubin greater than 1.4 mg/dL or AST or Alkaline Phosphatase greater than ULN.

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

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

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:



Final Approved VER: 03-02-16 (1519 VER: 11-23-15) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1: Provider select route of administration
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 azacitidine (Vidaza) __________mg (75 mg/m2) IV once over 30 minutes

 azacitidine (Vidaza) __________mg (75 mg/m2) subcutaneous once.


Treatment Medications for Day 2: Provider select route of administration
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 azacitidine (Vidaza) __________mg (75 mg/m2) IV once over 30 minutes

 azacitidine (Vidaza) __________mg (75 mg/m2) subcutaneous once.


Treatment Medications for Day 3: Provider select route of administration
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 azacitidine (Vidaza) __________mg (75 mg/m2) IV once over 30 minutes

 azacitidine (Vidaza) __________mg (75 mg/m2) subcutaneous once.


Treatment Medications for Day 4: Provider select route of administration
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 azacitidine (Vidaza) __________mg (75 mg/m2) IV once over 30 minutes

 azacitidine (Vidaza) __________mg (75 mg/m2) subcutaneous once.


Treatment Medications for Day 5: Provider select route of administration
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 azacitidine (Vidaza) __________mg (75 mg/m2) IV once over 30 minutes

 azacitidine (Vidaza) __________mg (75 mg/m2) subcutaneous once.


Treatment Medications: (continued on next page)

Final Approved VER: 03-02-16 (1519 VER: 11-23-15) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 6: Provider select route of administration
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 azacitidine (Vidaza) __________mg (75 mg/m2) IV once over 30 minutes

 azacitidine (Vidaza) __________mg (75 mg/m2) subcutaneous once.


Treatment Medications for Day 7: Provider select route of administration
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


 azacitidine (Vidaza) __________mg (75 mg/m2) IV once over 30 minutes

 azacitidine (Vidaza) __________mg (75 mg/m2) subcutaneous once.

Other Orders for Day 1, 2, 3, 4, 5, 6 and/or 7:











Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

• Acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth 2 times daily.

 Other:





Final Approved VER: 03-02-16 (1519 VER: 11-23-15) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 through 7 every 28 days

• Labs:
 Day 8 through 28: Obtain CBC, ANC (DIFF if done locally) twice weekly
 Other:






• Procedures/Imaging/Scans:













• Other Orders:









MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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