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GI Capecitabine(28D:1-14)/Temozolomide (28D:10-14) (5054 VER: 03-22-13)

GI Capecitabine(28D:1-14)/Temozolomide (28D:10-14) (5054 VER: 03-22-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 09-10-15 (5054 VER: 03-22-13) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Capecitabine/Temozolomide
Disease Group: Gastrointestinal
Disease: Pancreatic Endocrine Carcinoma (Advanced)

Therapy: capecitabine 750 mg/m2 by mouth twice daily Days 1 through 14,
temozolomide 200 mg/m2 by mouth once daily Days 10 through 14;

Cycle Length: 28 days Course: until disease progression

Reference(s): Strosberg J, et al. Cancer 2011;117:268-75.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1, Day 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total
Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase
 Other:


• Cycle 2+, Day 1: Obtain CBC with DIFF, Creatinine, Total Bilirubin, ALT
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1 (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:
• Flush/Line Care per Institution standards

Hydration/Fluids: none

Premedications/Antiemetics: none

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


• See Take Home Medication Section



Final Approved VER: 09-10-15 (5054 VER: 03-22-13) 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)
• Capecitabine (Xeloda) 750 mg/m2 by mouth 2 times daily for 14 days. Disp. # ____, Refills: 0
(Round dose to available tablet sizes of 500 mg and 150 mg.)

Take ______ mg in AM and ______ mg in PM daily beginning evening of ____________ (date) through
morning of ____________ (date).

• Temozolomide (Temodar) 200 mg/m2 by mouth once daily Days 10 through 14. Disp. # ____, Refills: 0
(Round dose to available capsule sizes of 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg.)

Take ______ mg by mouth one time daily beginning ____________ (date) through ____________ (date).
Swallow whole on empty stomach.

• Ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting. Take 1 tablet (8 mg) by mouth
before temozolomide Days 10 through 14.

 Other:




Follow Up
• Clinic Visit: Day 1 every 28 days

• Labs: Day 1 every 28 days
 Other:


• Procedures/Imaging/Scans:







• Other Orders:




MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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