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HEM Bortezomib(28D1,8,15,22)/Cyclophosphamide(28D1,8,15,22)/Dexamethasone(28D1-4,9-12,17-20) (4415 VER: 8-03-16)

HEM Bortezomib(28D1,8,15,22)/Cyclophosphamide(28D1,8,15,22)/Dexamethasone(28D1-4,9-12,17-20) (4415 VER: 8-03-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: x-xx-16 (4415 VER: 8-03-16) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bortezomib/Cyclophosphamide/Dexamethasone
Disease Group: Hematology
Disease: Multiple Myeloma

Therapy:
Cycle 1 and 2:
bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, and 22,
cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, and 22,
dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12, and 17 through 20
Cycle 3 and 4:
bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, and 22,
cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, and 22,
dexamethasone 40 mg by mouth Day 1, 8, 15, and 22

Cycle Length: 28 days Course: 4 cycles

Reference(s): Reeder CB, et al. Leukemia 2009;23:1337-41; Reeder CB, et al. Blood 2010;115:3416-7
Moreau P, et al. Lancet Oncol 2011;12:431-40.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 8 (date) ___________
 Day 15 (date) ___________  Day 22 (date) ___________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, ALT
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC without DIFF, ANC, Electrolytes, BUN, Creatinine,
Total Bilirubin, AST, ALT
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 75K/µL

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

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

Premedications/Antiemetics - None



Final Approved VER: x-xx-16 (4415 VER: 8-03-16) Page 2 of 4
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:


• dexamethasone (Decadron) 40 mg by mouth once. Omit if taken at home. See Take Home Medications.

• bortezomib (Velcade) __________mg (1.5 mg/m2) subcutaneous once

• cyclophosphamide (Cytoxan) ____________ mg (300 mg/m2) by mouth once. Omit if taken at home. See
Take Home Medications.

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:


• dexamethasone (Decadron) 40 mg by mouth once Cycles 3 and 4 ONLY. Omit if taken at home. See Take
Home Medications.

• bortezomib (Velcade) __________mg (1.5 mg/m2) subcutaneous once

• cyclophosphamide (Cytoxan) ____________ mg (300 mg/m2) by mouth once. Omit if taken at home. See
Take Home Medications.

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:


• dexamethasone (Decadron) 40 mg by mouth once Cycles 3 and 4 ONLY. Omit if taken at home. See Take
Home Medications.

• bortezomib (Velcade) __________mg (1.5 mg/m2) subcutaneous once

• cyclophosphamide (Cytoxan) ____________ mg (300 mg/m2) by mouth once. Omit if taken at home. See
Take Home Medications.



Treatment Medications (continued on next page)



Final Approved VER: x-xx-16 (4415 VER: 8-03-16) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 22: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 40 mg by mouth once Cycles 3 and 4 ONLY. Omit if taken at home.

• bortezomib (Velcade) __________mg (1.5 mg/m2) subcutaneous once

• cyclophosphamide (Cytoxan) ____________ mg (300 mg/m2) by mouth once. Omit if taken at home. See
Take Home Medications.

Other Orders for Day 1, 8, 15 and/or 22:








Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #120, Refills: 0
During Cycle 1 and 2, take 10 tablets (40 mg) by mouth on Day 1 through 4, Day 9 through 12, and Day 17
through 20.

• dexamethasone (Decadron) 4 mg tablet, Disp. #40, Refills: 0
During Cycle 3 and 4, take 10 tablets (40 mg) by mouth on Day 1, 8, 15, and 22.

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

• cyclophosphamide (Cytoxan) 50 mg capsule, Disp. #____, Refills: 0
Take ____ caps (300 mg/m2) by mouth once weekly. Take on Days 1, 8, 15, and 22.

• ranitidine (Zantac) 150 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (150 mg) by mouth 2 times daily.

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

 Other:



Final Approved VER: x-xx-16 (4415 VER: 8-03-16) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1, 8, 15 and 22 every 28 days

• Labs: None
 Other:






• Procedures/Imaging/Scans:













• Other Orders:











MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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