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GYN Carboplatin (21D1)Paclitaxel (21D1,8,15) (3457 VER: 4-21-14)

GYN Carboplatin (21D1)Paclitaxel (21D1,8,15) (3457 VER: 4-21-14) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 05-10-16 (3457 VER: 4-21-14) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carboplatin/Paclitaxel
Disease Group: Gynecology/Oncology
Disease: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced)

Therapy: PACLItaxel 80 mg/m2 IV Day 1, 8 and 15,
CARBOplatin (AUC = 4 to 6) IV Day 1,

Cycle Length: 21 days Course: Until disease progression

Reference(s): Katsumata N, et al. Lancet;2009:374:1331-8.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ________  Day 8 (date) ________  Day 15 (date) ________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, CA 125, Magnesium, BUN, Creatinine, Total
Bilirubin
 Other:


• Day 8 and 15: Obtain CBC without DIFF, ANC
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Day 8 and 15: Verify the following labs have been obtained: WBC, ANC, Platelets
• Hold and notify provider for:
 Cycle 1 Day 1: ANC ≤ 1500/µL or Platelets ≤ 100K/µL
 Cycle ≥ 2 Day 1: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Creatinine > ULN
 Day 8 and 15: ANC < 500/µL or Platelets < 50K/µL
• Cycle 1 Day 1, 8 and 15: 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







Final Approved VER: 05-10-16 (3457 VER: 4-21-14) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to PACLItaxel:
• diphenhydramine (Benadryl) 50 mg IV once
• ranitidine (Zantac) 50 mg IV once
• Cycle 1: dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
• Cycle 2+: dexamethasone (Decadron) 10 mg IV once.

Day 1 Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *Day 1: 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:

Day 8 & 15 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:

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 (80 mg/m2) in non-PVC Bag IV once through non-PVC tubing and
standard in-line filter. Administer over 60 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.


• CARBOplatin (Paraplatin) __________ mg (Dosed AUC = ______) 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

Final Approved VER: 05-10-16 (3457 VER: 4-21-14) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Treatment Medications for Day 8: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• PACLItaxel (Taxol) __________mg (80 mg/m2) in non-PVC Bag IV once through non-PVC tubing and
standard in-line filter. Administer over 60 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.


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:


• PACLItaxel (Taxol) __________mg (80 mg/m2) in non-PVC Bag IV once through non-PVC tubing and
standard in-line filter. Administer over 60 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.


Other Orders for Day 1, 8 and/or 15:





Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #46, Refills: 0
Take 3 tablets (12 mg) by mouth 12 hours and 6 hours before 2
nd
PACLItaxel dose and 2 tablets (8 mg) by
mouth 12 hours and 6 hours before 3
rd
PACLItaxel dose. In addition, take 2 tablets (8 mg) by mouth once daily
for 3 days after each CARBOplatin dose.

• 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:








Final Approved VER: 05-10-16 (3457 VER: 4-21-14) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1, 8 and 15 every 21 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 #: ________