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Lung Osimertinib(21D:1-21) (5935 VER: 02-18-16)

Lung Osimertinib(21D:1-21) (5935 VER: 02-18-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 03-01-16 (5935 VER: 02-18-16) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Osimertinib
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Advanced)

Therapy: osimertinib 80 mg by mouth once daily continuously

Cycle Length: 21 days Course: until disease progression

Note to All Staff: Chemotherapy Council approved for NSCLC patients harboring epidermal growth factor
(EGFR) resistance mutation T790M.

Reference(s): Janne PA, et al. N Engl J Med. 2015;372(18):1689-99; Mitsudomi T, et al. Presented at the 16
th

World Conference on Lung Cancer; September 2015;Denver, CO. Abstract 1406.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Obtain CBC without DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total
Bilirubin, AST, ALT, Alkaline Phosphatase
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: Total Bilirubin, AST, ALT
• Hold and notify provider for: Total Bilirubin > 3 X ULN or AST > 5 X ULN or ALT > 5 X ULN
• Verify baseline and every 3 month ECHO or MUGA obtained.

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

Hydration/Fluids: None

Premedications/Antiemetics: 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: 03-01-16 (5935 VER: 02-18-16) 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)
• osimertinib mesylate (Tagrisso) 80 mg tablet, Disp. #30, Refills: ____
Take 1 tablet (80 mg) by mouth once daily.

• 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 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 #: ________