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Breast Letrozole (28D1-28)/Palbociclib (28D1-21) (5633 VER: 04-29-15)

Breast Letrozole (28D1-28)/Palbociclib (28D1-21) (5633 VER: 04-29-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 03-23-16 (5633 VER: 04-29-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Letrozole/Palbociclib
Disease Group: Breast
Disease: Breast Cancer (Advanced)

Therapy: palbociclib 125 mg by mouth once daily Days 1 through 21,
letrozole 2.5 mg by mouth once daily continuously Days 1 through 28

Cycle Length: 28 days Course: until disease progression

Reference(s): Finn RS, et al. Lancet Oncol 2015;16(1):25-35.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC with DIFF, Creatinine, AST, Total Bilirubin
• Hold and notify provider for: ANC < 1000/µL or Platelets ≤ 100K/µL or Creatinine > 2 mg/dL or Total Bilirubin >
1.5 x ULN or AST > 5 x ULN

Nursing Procedure, Assessment and Monitoring: Flush/Line Care per Institution standards

Hydration/Fluids: None

Premedications/Antiemetics: (May substitute formulary equivalent) - None

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:


• See Take Home Medication section

Other Orders for Day 1






Final Approved VER: 03-23-16 (5633 VER: 04-29-15) 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)
• palbociclib (Ibrance) 125 mg capsule, Disp. #21, Refills: _____
Take 1 capsule (125 mg) by mouth once daily on Days 1 through 21 of 28-day cycle. Swallow whole with food.

• letrozole (Femara) 2.5 mg tablet, Disp. #30, Refills: ______
Take 1 tablet (2.5 mg) by mouth once daily

• 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
• Clinic Visit: Day 1 every 28 days

• Labs:
 Day 15 (Cycles 1 and 2 only) – Obtain CBC, ANC (DIFF if done locally)
 Other:


• Procedures/Imaging/Scans:










• Other Orders:








MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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