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Lung Crizotinib(28D:1-28) (4425 VER: 03-05-15)

Lung Crizotinib(28D:1-28) (4425 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 11-10-15 (4425 VER: 03-05-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Crizotinib
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Advanced, ALK- positive)

Therapy: crizotinib 250 mg by mouth twice daily continuously

Cycle Length: 28 days Course: until disease progression

Note to All Staff: Crizotinib prolongs the QT interval and should be used with caution in patients with
hypokalemia, hypomagnesemia, or long QT syndrome as sudden death has been reported in these patients.

Reference(s): Riely GJ, et al. Profile 1005. World Conference on Lung Cancer July 2011. Abstract 1618; Kwak
EL, et al. N Engl J Med 2010;363:1693-703; Camidge DR, et al. J Clin Oncol 29:2011 (suppl; abstr 2501)

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

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


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: ANC, Platelets, AST, ALT, Alkaline Phosphatase, Total Bilirubin
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or AST greater than or equal to ULN or
ALT greater than or equal to ULN or Alkaline Phosphatase ≥ to ULN or Total Bilirubin ≥ ULN.

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

Hydration/Fluids: None

Premedications/Antiemetics: None

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:


• See Take Home Medication section


Other Orders for Day 1:




Final Approved VER: 11-10-15 (4425 VER: 03-05-15) Page 2 of 2
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)
• crizotinib (Xalkori) 250 mg capsule, Disp. #60, Refills: ____
Take 1 capsule (250 mg) by mouth 2 times daily.


 Other:



Follow Up
• Chemotherapy: Day 1 every 28 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 #: ________