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GI Paclitaxel Protein-Bound (28D:1,8,15) Gemcitabine(28D:1,8,15) (4989 VER: 10-02-13)

GI Paclitaxel Protein-Bound (28D:1,8,15) Gemcitabine(28D:1,8,15) (4989 VER: 10-02-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 01-22-16 (4989 VER: 10-02-13) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Gemcitabine/Paclitaxel Protein-Bound
Disease Group: Gastrointestinal
Disease: Pancreatic Cancer (Advanced)

Therapy: PACLitaxel protein-bound 100 to 150 mg/m2 IV Day 1, 8, and 15
gemcitabine 1000 mg/m2 IV Day 1, 8, and 15

Cycle Length: 28 days Course: until disease progression

Reference(s): Von Hoff D, et al. J Clin Oncol 2013;31 (suppl 4; abstr LBA148)

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, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase
 Other:


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



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1, 8, and 15: Verify the following labs have been obtained: ANC, Platelets
• Day 1, 8, and 15: 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: (May substitute formulary equivalent)

Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *dexamethasone (Decadron) 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:






Final Approved VER: 01-22-16 (4989 VER: 10-02-13) Page 2 of 3
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 protein-bound (Abraxane) __________ mg (Dosed at __________ mg/m2 (100 to 150 mg/m2)) IV
once over 30 minutes

• gemcitabine (Gemzar) __________ mg (1000 mg/m2) IV once over 30 minutes
Additional sodium chloride 0.9% may be y-set into IV site to decrease irritation.


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 protein-bound (Abraxane) __________ mg (Dosed at __________ mg/m2 (100 to 150 mg/m2)) IV
once over 30 minutes

• gemcitabine (Gemzar) __________ mg (1000 mg/m2) IV once over 30 minutes
Additional sodium chloride 0.9% may be y-set into IV site to decrease irritation.


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 protein-bound (Abraxane) __________ mg (Dosed at __________ mg/m2 (100 to 150 mg/m2)) IV
once over 30 minutes

• gemcitabine (Gemzar) __________ mg (1000 mg/m2) IV once over 30 minutes
Additional sodium chloride 0.9% may be y-set into IV site to decrease irritation.

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










Final Approved VER: 01-22-16 (4989 VER: 10-02-13) Page 3 of 3
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)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

 Other:



Follow Up
• Chemotherapy: Day 1, 8, and 15 every 28 days

• Procedures/Imaging/Scans:









• Other Orders:










MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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