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GYN Bevacizumab(21D1)/Cisplatin(21D1)/Paclitaxel(21D1)

GYN Bevacizumab(21D1)/Cisplatin(21D1)/Paclitaxel(21D1) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 05-11-16 (5369 VER: 07-14-14) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Bevacizumab/Cisplatin/Paclitaxel
Disease Group: Gynecology/Oncology
Disease: Cervical, Vulvar, Vaginal Cancer (Advanced)

Therapy: bevacizumab 15 mg/kg IV Day 1,
PACLItaxel 175 mg/m2 IV Day 1,
CISplatin 50 mg/m2 IV Day 1

Cycle Length: 21 days Course: until disease progression

Reference(s): Tewari KS, et al. N Engl J Med 2014;370(8):734-43

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total
Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium, Urinalysis with Microscopy
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin, Urinalysis with
Microscopy
• Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL or Creatinine > ULN or Total Bilirubin > 1.6
mg/dL or AST > 5 X ULN or Urine Protein ≥ 100 mg/dL or Blood Pressure ≥ 160/90 mmHg
• Cycles 1, 2 and 3: Verify that patient has taken home dexamethasone and document.


Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion
complete for the first and second dose of PACLItaxel administration. Monitor vital signs every 30 minutes for
all subsequent doses if previous doses tolerated.
• Measure IV intake and urine output. If IV intake is greater than 2000 mL and urine output is less than 500 mL,
give furosemide. See Conditional Orders section.
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV administer 1000 mL prior to or throughout CISplatin infusion.
 Additional additives required – these may be added to any appropriate fluid throughout treatment
 Magnesium ______ grams
 Potassium chloride ______ mEq


Final Approved VER: 05-11-16 (5369 VER: 07-14-14) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to paclitaxel:
• diphenhydramine (Benadryl) 50 mg IV once.
• ranitidine (Zantac) 50 mg IV once.
• Cycles 1, 2, and 3: dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take
dexamethasone at home.
• Cycles 4+: dexamethasone (Decadron) 10 mg IV once.

Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 24 mg by mouth once. PO preferred – may give 12 mg IV if unable to tolerate PO.
 fosaprepitant (Emend) 150 mg IV once.
 *aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:


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:




• bevacizumab (Avastin) __________mg (15 mg/kg) IV once. Administer first dose over 90 minutes. If tolerated,
give 2
nd
dose over 60 minutes; if tolerated, give 3
rd
dose over 30 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. If infusion-related reactions occur, all subsequent infusions should be administered over
the shortest period that was well tolerated.

• PACLItaxel (Taxol) ____________ mg (175 mg/m2) in non-PVC Bag IV once through non-PVC tubing and
standard in-line filter. Administer over 180 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care.

• CISplatin (Platinol) __________ mg (50 mg/m2) IV once over 60 to 90 minutes.



Conditional Orders Day 1:
• furosemide (Lasix) 20 mg IV once PRN. IV push rate 10 mg/minute. Administer if IV intake is greater than
2000 mL and urine output is less than 500 mL.


Other Orders for Day 1:


Final Approved VER: 05-11-16 (5369 VER: 07-14-14) Page 3 of 3
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)
• dexamethasone (Decadron) 4 mg tablet, Disp. #46, Refills: 0
Take 3 tablets (12 mg) by mouth 12 hours and 6 hours before 2
nd
PACLItaxel dose and 2 tablets (8 mg) by
mouth 12 hours and 6 hours before 3
rd
PACLItaxel dose. In addition, take 2 tablets (8 mg) by mouth once daily
for 3 days after each CISplatin dose.

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

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

 aprepitant (Emend) 80 mg capsule, Disp. #2, Refills: 5
Take 1 capsule by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

 Other:




Follow Up
• Chemotherapy: Day 1 every 21 days

• Labs:
 Day 10 – 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 #: ________