PROCRITline.com - Oncology Toolkit - Chemotherapy Treatment Notes/Flow Sheet

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Please see full Prescribing Information, including Boxed WARNINGS, for PROCRIT^® (Epoetin alfa)

Please see full Prescribing Information, including Boxed WARNINGS, for LEUSTATIN^® (cladribine)

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Chemotherapy Treatment Notes/Flow Sheet

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Oncology Toolkit

Chemotherapy Treatment Notes/Flow Sheet

The information contained in this document is provided for information purposes only and represents no statement, promise or guarantee by Centocor Ortho Biotech Inc. concerning levels of reimbursement, payment, or charge. We strongly suggest that you consult your payor organization with regard to local reimbursement policies.

Chemotherapy Treatment Notes

Patient Name: ______________________________ Pt. Acct # ____________________ M.D. ______________

Date: ___/____/___    r Pre Rx Laboratories Checked    Redness, Swelling or Discomfort at site    r Yes(explain below)    r No

IV Administration: r Peripheral r Port r Hickman r Groshong r PICC
r Other _________________________________

Blood Return: r Present r Not Present (explain below) r Left r Right
Port Flushed per Protocol ____________________

r Butterfly    r Cannula    r Huber/Gripper    r Needle    Site ____________________ r Dorsal r Plantar

Drug or Treatment	Dose	Reconstituted	IV Solution	Solution Size	Route	Time On	Time Off	Notes
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA

Notes:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

M.D. On Site

Date: ___/____/___    r Pre Rx Laboratories Checked    Redness, Swelling or Discomfort at site    r Yes(explain below)    r No

IV Administration: r Peripheral r Port r Hickman r Groshong r PICC
r Other _________________________________

Blood Return: r Present r Not Present (explain below) r Left r Right
Port Flushed per Protocol ____________________

r Butterfly    r Cannula    r Huber/Gripper    r Needle    Site ____________________ r Dorsal r Plantar

Drug or Treatment	Dose	Reconstituted	IV Solution	Solution Size	Route	Time On	Time Off	Notes
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA
		With________________ ________________ Amt.______		50 / 100 150 / 250 500 / 1000	PO IM IVP IV IA PUMP INTRA

Important Safety Information for PROCRIT^® (Epoetin alfa)

WARNINGS: INCREASED MORTALITY, SERIOUS CARDIOVASCULAR EVENTS, THROMBOEMBOLIC EVENTS, STROKE and INCREASED RISK OF TUMOR PROGRESSION OR RECURRENCE

Chronic Renal Failure:

In clinical studies, patients experienced greater risks for death, serious cardiovascular events, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target hemoglobin levels of 13 g/dL and above.

Individualize dosing to achieve and maintain hemoglobin levels within the range of 10 to 12 g/dL.

Cancer:

ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in some clinical studies in patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers (see WARNINGS: Table 1).

To decrease these risks, as well as the risk of serious cardio- and thrombovascular events, use the lowest dose needed to avoid red blood cell transfusion.

Because of these risks, prescribers and hospitals must enroll in and comply with the ESA APPRISE Oncology Program to prescribe and/or dispense PROCRIT^® to patients with cancer. To enroll in the ESA APPRISE Oncology Program, visit www.esa-apprise.com or call 1-866-284-8089 for further assistance.

Use ESAs only for treatment of anemia due to concomitant myelosuppressive chemotherapy.

ESAs are not indicated for patients receiving myelosuppressive therapy when the anticipated outcome is cure.

Discontinue following the completion of a chemotherapy course.

Perisurgery: PROCRIT^® (Epoetin alfa) increased the rate of deep venous thromboses in patients not receiving prophylactic anticoagulation. Consider deep venous thrombosis prophylaxis.

(See WARNINGS: Increased Mortality, Serious Cardiovascular Events, Thromboembolic Events, and Stroke, WARNINGS: Increased Mortality and/or Increased Risk of Tumor Progression or Recurrence, INDICATIONS AND USAGE, and DOSAGE AND ADMINISTRATION.)

Please see full Prescribing Information, including Boxed WARNINGS for PROCRIT^® (Epoetin alfa)

Medication Guide for PROCRIT^®
Please read the Medication Guide for PROCRIT^® and discuss with your doctor.

Patient Instructions for Use
Instructions if you or your caregiver has been trained to give PROCRIT^® injections at home.

Boxed WARNINGS: LEUSTATIN^® (cladribine) Injection

LEUSTATIN (cladribine) Injection should be administered under the supervision of a qualified physician experienced in the use of antineoplastic therapy. Suppression of bone marrow function should be anticipated. This is usually reversible and appears to be dose dependent. Serious neurological toxicity (including irreversible paraparesis and quadraparesis) has been reported in patients who received LEUSTATIN Injection by continuous infusion at high doses (4 to 9 times the recommended dose for Hairy Cell Leukemia). Neurologic toxicity appears to demonstrate a dose relationship; however, severe neurological toxicity has been reported rarely following treatment with standard cladribine dosing regimens.

Acute nephrotoxicity has been observed with high doses of LEUSTATIN (4 to 9 times the recommended dose for Hairy Cell Leukemia), especially when given concomitantly with other nephrotoxic agents/therapies.

Please see full Prescribing Information, including Boxed WARNINGS for LEUSTATIN^® (cladribine)