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GI Trifluridine-Tipiracil (28D1-5,8-12) (5521 VER: 11-24-15)

GI Trifluridine-Tipiracil (28D1-5,8-12) (5521 VER: 11-24-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 02-16-16 (5521 VER: 11-24-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Trifluridine/Tipiracil
Disease Group: Gastrointestinal
Disease: Colon Cancer (Advanced)

Therapy: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and Days 8 through 12

Cycle Length: 28 days Course: until disease progression

Reference(s): Mayer RJ, et al. N Engl J Med 2015;372(20):1909-19

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin,
AST, ALT, Carcinoembryonic Antigen (CEA)
 Other:


• Cycle 2+: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Carcinoembryonic
Antigen (CEA)
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Cycle 1: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin
 Cycle 2+: CBC, ANC
• Hold and notify provider for:
 Cycle 1: ANC < 1500/µL or Platelets ≤ 100K/µL or Total Bilirubin ≥ 1.5 mg/dL (unless solely due to medical
diagnosis of Gilbert’s syndrome) or AST ≥ 3 X ULN or ALT ≥ 3 X ULN or Creatinine ≥ 1.5 mg/dL
 Cycle 2: ANC < 1500/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: See Take Home Medication Section

Other Orders for Day 1:






Final Approved VER: 02-16-16 (5521 VER: 11-24-15) 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)
 trifluridine-tipiracil (Lonsurf) 15-6.14 mg tablet, Disp. # __________, Refills: 0
Dose = 35 mg/m2 (based on trifluridine component, maximum 80 mg/dose. Round dose to nearest 5 mg
increment)

Take _______ tablets ( _______ mg) by mouth twice daily within 1 hour after AM and PM meals on Days 1
through 5 and Days 8 through 12.

 trifluridine-tipiracil (Lonsurf) 20-8.19 mg tablet, Disp. # __________, Refills: 0
Dose = 35 mg/m2 (based on trifluridine component, maximum 80 mg/dose. Round dose to nearest 5 mg
increment)

Take _______ tablets ( _______ mg) by mouth twice daily within 1 hour after AM and PM meals on Days 1
through 5 and Days 8 through 12.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

• loperamide (Imodium) 2 mg tablet, Disp. Available OTC
Take 2 tablets (4 mg) by mouth with 1
st
loose stool followed by 1 tab every 2 hours or 2 tablets every 4 hours
until no diarrhea for 12 hours. Max dose = 8 tablets/day

 Other:



Follow Up
• Chemotherapy: Day 1 and every 28 days

• Labs: Cycle 1, Day 15 – Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium
 Other:


• Procedures/Imaging/Scans:




• Other Orders:



MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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