/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/ppo/,

/clinical/cckm-tools/content/ppo/name-99096-en.cckm

201608217

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Preprinted Paper Orders

Breast Eribulin (21D1,8) (4434 VER: 2-18-15)

Breast Eribulin (21D1,8) (4434 VER: 2-18-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 11-4-15 (4434 VER: 2-18-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Eribulin
Disease Group: Breast
Disease: Breast Cancer (Advanced)

Therapy: eriBULin 1.4 mg/m2 IV Day 1 and 8

Cycle Length: 21 days Course: until disease progression

Note: Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte
abnormalities.

Reference(s): Cortes J, et al. Lancet 2011;377:914-23

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin, Alkaline Phosphatase, Calcium,
Magnesium, Potassium
 Other:


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


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1: CBC, ANC, Total Bilirubin, Creatinine, Magnesium, Potassium
 Day 8: CBC, ANC
• Hold and notify provider for:
 Day 1: ANC < 1000/µL or Platelets < 100K/µL or Total Bilirubin > 1.5 X ULN or Creatinine > 1.5 X ULN or
Magnesium outside of normal limits or Potassium outside of normal limits
 Day 8: ANC < 1000/µL or Platelets < 100K/µL

Nursing Procedure, Assessment and Monitoring:
• Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of
toxicity.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics
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: 11-4-15 (4434 VER: 2-18-15) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:

• eriBULin mesylate (Halaven) __________mg (1.4 mg/m2) IV once over 2 to 5 minutes.
Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products.

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

• eriBULin mesylate (Halaven) __________mg (1.4 mg/m2) IV once over 2 to 5 minutes.
Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products.

Other Orders for Day 1 and/or 8:


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.

 Other:


Follow Up
• Chemotherapy: Day 1 and 8 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 #: ________