/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/ppo/,

/clinical/cckm-tools/content/ppo/name-99114-en.cckm

201608217

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Preprinted Paper Orders

Breast Trastuzumab (21D1) (5668 VER: 04-15-15)

Breast Trastuzumab (21D1) (5668 VER: 04-15-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 8-3-15 (5668 VER: 04-15-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Trastuzumab
Disease Group: Breast
Disease: Breast Cancer (Neoajuvant/Adjuvant)

Therapy: trastuzumab 6 mg/kg IV Day 1

Cycle Length: 21 days Course: 13 cycles

Note: This regimen follows treatment with cyclophosphamide/doxorubicin/pertuzumab/trastuzumab/paclitaxel.

Reference(s): Citron ML, et al. J Clin Oncol 2003;21:1431-39. Gianni L, et al. Lancet Oncol 2012;13(1):25-32.
Schneeweiss A, et al. Ann Oncol 2013;24(9):2278-84.
Datko F, et al. Cancer Res 2012;72(24 Suppl):Abstract 18-20.


Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
 Other:



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.

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

Hydration/Fluids:
• Day 1: sodium chloride 0.9% IV to establish line and for flushing

Premedications/Antiemetics: None

Treatment Medications for Day 1:
• trastuzumab (Herceptin) __________mg (6 mg/kg) 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:







Final Approved VER: 8-3-15 (5668 VER: 04-15-15) 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)
 Other:



Follow Up
• Chemotherapy: Day 1 every 21 Days

• Labs:
 Other:



• Procedures/Imaging/Scans:















• Other Orders:






MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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