Example orders for Oxaliplatin (Eloxatin) desensitization protocol

Remember that example order sets that may contain additional information about supportive medications, suggestions for monitoring, hydration, and pre-treatment screening information for chemotherapy regimens are purely anecdotal, provided only as examples of what some other providers may be using, and are typically not based on references in the primary literature.
==Oxaliplatin (Eloxatin) desensitization protocol==
Original references may be found at Oxaliplatin desensitization protocol
===Example regimen #1===
*Solution #1 of Oxaliplatin (Eloxatin) 0.013 mg/m2 IV over 60 minutes, given first
**Mixed in 100 mL D5W
*Solution #2 of Oxaliplatin (Eloxatin) 0.13 mg/m2 IV over 60 minutes, given second
**Mixed in 100 mL D5W
*Solution #3 of Oxaliplatin (Eloxatin) 1.3 mg/m2 IV over 60 minutes, given third
**Mixed in 100 mL D5W
*Solution #4 of Oxaliplatin (Eloxatin) 13 mg/m2 IV over 60 minutes, given fourth
**Mixed in 100 mL D5W
*Solution #5 of Oxaliplatin (Eloxatin) 117 mg/m2 IV, with 493.83 mL of the 500 mL solution given over 237.04 minutes, given fifth
**Mixed in 500 mL D5W; only 493.83 mL of the 500 mL solution will be given, so that the correct total dose is administered, not slightly more than the intended amount.
*Patient is also using Capecitabine (Xeloda) as part of the CapeOx regimen--see comments below.
21-day cycles
====Supportive therapy====
*Diphenhydramine (Benadryl) 25 mg IV 30-60 minutes prior to the start of oxaliplatin
*Famotidine (Pepcid) 20 mg IV over 15 minutes, 30-60 minutes prior to the start of oxaliplatin
*Lorazepam (Ativan) 0.5-1 mg PO prn nausea, anxiety 30-60 minutes prior to the start of oxaliplatin
*Montelukast (Singulair) 10 mg PO 60 minutes prior to the start of oxaliplatin
*Methylprednisolone (Solumedrol) 40 mg IV 30-60 minutes prior to the start of oxaliplatin
*Diphenhydramine (Benadryl) 25-50 mg IV or PO prn allergic reaction 
**If the patient develops a mild reaction, such as fever, self-limiting rash, itching, mild chest tightness, abdominal or back pain, nausea, another dose of Diphenhydramine (Benadryl) 25-50 mg IV or PO may be given. Observe until the reaction improves, then resume the infusion at the point where it was stopped. If the reaction does not improve within 30 minutes, contact the allergist on call.
*Epinephrine (Epipen) 0.3 mg IM prn allergic reaction
**If the patient develops a moderate to severe reaction, such as acute dyspnea or angioedema, and/or acute hypotension, stop protocol, follow ACLS guidelines to treat, use Epinephrine (Epipen) 0.3 mg IM for hypotension or glottic edema, and nebulized albuterol for bronchospasm. Discuss the event with the attending allergy physician on call. When the patient is stable, the protocol may be resumed (with allergist's guidance regarding the rate at which to restart and with revisions if necessary).
*Calcium gluconate 1 g & magnesium sulfate 1 g (admixed together) IV, given over 30 minutes, to start prior to oxaliplatin to decrease likelihood of neuropathy
*Calcium gluconate 1 g & magnesium sulfate 1 g (admixed together) IV, given over 30 minutes, to start after oxaliplatin infusion is complete to decrease likelihood of neuropathy
*Calcium and magnesium no longer recommended to reduce risk of oxaliplatin-induced neuropathy: Charles L. Loprinzi, Rui Qin, Shaker R. Dakhil, Louis Fehrenbacher, Philip J. Stella, Pamela J. Atherton, Drew K. Seisler, Rubina Qamar, Grant Carlton Lewis, Axel Grothey. Phase III randomized, placebo (PL)-controlled, double-blind study of intravenous calcium/magnesium (CaMg) to prevent oxaliplatin-induced sensory neurotoxicity (sNT), N08CB: An alliance for clinical trials in oncology study. 2013 ASCO Annual Meeting abstract 3501. link to abstract
*Fosaprepitant (Emend injection) 150 mg IV x1 prior to oxaliplatin
*Ondansetron (Zofran) 8 mg IV 30 minutes prior to oxaliplatin
Hydration:
*500 ml D5W at KVO rate as running IV for chemotherapy infusion. Give up to 500 ml D5W.
Monitoring:
*Hold if ANC less than 1000 or platelets less than 100 and notify physician.
Clinical scenario & comments:
59 year-old lady with metastatic colon cancer, previously treated with and progressed on FOLFIRI & Bevacizumab (Avastin), Cetuximab (Erbitux) & Irinotecan (Camptosar), who was hospitalized after cycle 2 of CapeOx because she developed an allergic reaction to Oxaliplatin (Eloxatin). Her Capecitabine (Xeloda) dose with this regimen is been 1000-1500 mg PO twice per day on days 1 to 14, with the start of capecitabine during this cycle delayed until after the desensitization protocol is completed.
Category:Example chemotherapy order sets
Category:Clinical pharmacology