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Breast Everolimus(28D:1-28) (4808 VER: 02-18-15)

Breast Everolimus(28D:1-28) (4808 VER: 02-18-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 03-09-16 (4808 VER: 02-18-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Everolimus
Disease Group: Breast
Disease: Breast Cancer (Advanced)

Therapy: everolimus 10 mg by mouth daily continuously

Cycle Length: 28 days (Cycle 1) and 56 days (Cycle ≥2) Course: until disease progression

Note: must be used with exemestane

Reference(s): Baselga J, et al. N Eng J Med 2012;366(6):520-9

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Lipid Panel
 Other:

• Cycle ≥ 2: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC with DIFF
• Hold and notify provider for ANC < 1000/µL or Platelets < 75K/µL

Nursing Procedure, Assessment and Monitoring:
• Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If
mouth sores become severe, contact the clinic.
• Flush/Line Care per Institution standards

Hydration/Fluids: None

Premedications/Antiemetics: None

Treatment Medications for Day 1: See Take Home Medication Section

Other Orders for Day 1:









Final Approved VER: 03-09-16 (4808 VER: 02-18-15) 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)
• everolimus (Afinitor) 10 mg tablet, Disp. #28, Refills:_____
Take 1 tablet (10 mg) by mouth once daily.

• exemestane (Aromasin) 25 mg tablet, Disp. #30, Refills: _____
Take 1 tablet (25 mg) by mouth once daily.

 Other:



Follow Up
• Clinic Visit: Day 1 every 28 days for Cycle 1, followed by Day 1 every 56 days for Cycle ≥ 2

• Labs:
 Other:



• Procedures/Imaging/Scans:









• Other Orders:







MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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