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GI Carboplatin(28D1,8,15)/Paclitaxel(28D1,8,15)

GI Carboplatin(28D1,8,15)/Paclitaxel(28D1,8,15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-23-15 (986 VER: 03-04-15) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Carboplatin/Paclitaxel
Disease Group: Gastrointestinal
Disease: Esophageal, Gastric, Gastroesophageal Junction Cancer (Neo-Adjuvant)

Therapy: PACLItaxel 50 mg/m2 IV Day 1, 8 and 15,
CARBOplatin (AUC = 2) IV Day 1, 8 and 15

Cycle Length: 28 days Course: until disease progression

Reference(s): Moosmann P, et al. Onkologie 2003;26:568-72

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, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase, Magnesium, Glucose
 Other:

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

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

Premedications/Antiemetics
Give prior to PACLItaxel:
• dexamethasone (Decadron) 20 mg IV once PRN. For use in patients who did not take dexamethasone at
home.
• diphenhydramine (Benadryl) 50 mg IV once.
• ranitidine (Zantac) 50 mg IV once.

Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:

Final Approved VER: 12-23-15 (986 VER: 03-04-15) 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:


• PACLItaxel (Taxol) __________mg (80 mg/m2) IV once with non-PVC tubing and 0.22 micron in-line filter over
60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• CARBOplatin (Paraplatin) ____________ mg (AUC = 2) IV once over 30 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



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) IV once with non-PVC tubing and 0.22 micron in-line filter over
60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• CARBOplatin (Paraplatin) ____________ mg (AUC = 2) IV once over 30 minutes. Hypersensitivity risk. For
first and second dose, patient should be treated in a location to optimize emergency care.







Final Approved VER: 12-23-15 (986 VER: 03-04-15) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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) IV once with non-PVC tubing and 0.22 micron in-line filter over
60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• CARBOplatin (Paraplatin) ____________ mg (AUC = 2) IV once over 30 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. #50, Refills: 1
Take 3 tablets (12 mg) by mouth 12 & 6 hours prior to 2
nd
PACLItaxel dose and 2 tabs (8 mg) 12 & 6 hours
prior to remaining PACLItaxel doses.

• 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, 8 and 15 every 28 days

• Labs: None
 Other:


• Procedures/Imaging/Scans:






• Other Orders:




Final Approved VER: 12-23-15 (986 VER: 03-04-15) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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