Download Bladder Cancer: MVAC every 28 days

Adult Outpatient Chemotherapy Order Form
Diagnosis / Indications: Bladder Cancer
Patient Height (cm): __________
Regimen: MVAC Every 28 Days
Weight (kg): Actual __________ Ideal: __________ Used: __________
Cycle:
Body Surface Area (m2): Actual: ________ Ideal: ________ Used: ____
Sternberg CN, et al. J Clin Oncol
Reference:
2001:19:2638-46. Grossman HB, et al. N Engl J
Med 2003;349:859-66
Allergies (reactions):
Begin Therapy Day # 1 _____ / _____ / _____
Lifetime Dose:
PROTOCOL
DOSAGE
2
DRUG
(Oral or injectable)
1
(Per M or Per Kg)
PATIENT’S
DOSE
30 mg/m2
Methotrexate
Vinblastine
3 mg/m2
30 mg/m2
Days 2, 15, and 22
IV
Day 2
Flow Rate or Infusion Time: 15 minutes
Fluid / Volume: NS 100 mL
[EF (date) ________________ = __________%]
Cisplatin
Days 1, 15, and 22
Flow Rate or Infusion Time: 10 minutes
Doxorubicin
4
IV
IV
Fluid / Volume: NS 50 mL
3
GIVE ON DAYS
Flow Rate or Infusion Time: 5 minutes
Fluid / Volume: NS 100 mL
2
ROUTE
70 mg/m2
IV
Fluid / Volume: NS 500 mL
Day 2
Flow Rate or Infusion Time: 60 minutes
Serum creatinine: __________
Follow-up appt.: ________________________________ with labs _______________________________________
Specific Administration Instructions/Requirements:
h ANC greater than 1,000 h ANC greater than 1,500 h Platelets greater than 100,000
1. Institute extravasation protocol in the event of a suspected extravasation
2. Monitor for hypersensitivity/allergic reaction. If suspected, follow hypersensitivity/anaphylaxis orders per the Emergency
Physician’s Order protocol.
Labs:
h CBC w/diff
h CMP
h BMP
h magnesium
h LFT
h Other ___________________
Pre-medications:
1. Dexamethasone 12 mg IV x 1 dose Days 1, 2, 15, 22
4. 1,000 mL NS IV over one to two hours pre-hydration Day 2
2. Ondansetron 8 mg IV x 1 dose Day 2
5. 1,000 mL NS with 20 mEq potassium and 2 grams magnesium per liter
3. Aprepitant 125 mg PO Day 2 (patient takes own medication)
IV over one to two hours post-hydration Day 2. Hold potassium for
serum level greater than 4.5 mmol/L.
PRN Medications (please check appropriate meds):
h Lorazepam 1 mg IV PRN nausea or anxiety x 1dose Days 1, 2, 15, 22
h Prochlorperazine 10 mg IV PRN N/V x 1 dose Days 1, 2, 15, 22
h Promethazine 25 mg IV PRN N/V x 1 dose Days 1, 2, 15, 22
h Furosemide ______ mg IV x 1 dose Day 2 PRN diuresis
Take-home medications (please check appropriate meds):
1. Aprepitant 80 mg PO Days 3 and 4 #_______
2. Dexamethasone 8 mg PO every morning Days 3, 4, and 5 #_______
h Prochlorperazine 10 mg PO every 6 hrs PRN nausea and vomiting #_______
h Promethazine 25 mg PO every 6 hrs PRN nausea and vomiting #_______
Special Instructions: ________________________________________________________________________________________________________________
Date ____________ Time ________ Physician / PA / RPh __________________________ Provider # ________________ Beeper # __________________
Date ____________ Time ________ Signature of Oncology Attending / Fellow ___________________________________________________________MD
Print Name of Attending / Fellow ____________________________________________________________________ MD # ___________________________
Pharmacy Use Only:
085087-1
Patient Name:
Patient Identification #:
*RX0001*
RX0001
Adult Outpatient Chemotherapy Order Form
(page 1 of 1)
3/3/11
PS85087
3/15/11