HME HGM HRV

MCH
x
MGH x RVH *FMU-2150*
HNM ITM CL
MNH MCI LC

Pharmacie
Temozolomide/Irinotecan/Vincristine
Pharmacy
Relapsed/refractory rhabdomyosarcoma Page 1 of 2
q 3 weeks cycle
CODE: Temozolomide_Irino_Vincrisitine (S)
Cycle # ______ Allergies (with reaction):
Treatment Date: Height (cm): Weight (kg): BSA (m2):
AAYY/MM/JD

Parameters - To be given IF within the last 72 hours (day 1) and 24 hours (day 8) Pharmacist comments
 Absolute neutrophil count greater than or equal to 1.0 x 109/L OR
 Platelets greater than or equal to 100 x 109/L OR
Note: CBC to be done on day 8, but vincristine should be given regardless of counts
 Other:
Pre-hydration Untick checkbox to strike out and modify
 D5W for primary IV line to KVO OR
Pre- treatment (Day 1: moderate emetogenic potential, day 8: low emetogenic potential) Untick checkbox to strike out
 Cefixime 400 mg PO daily for for 10 days to start 2 days prior to day 1 (every
cycle). Avoid if type 1 penicillin allergy. If patient didn’t take it prior, start on Day 1
for 10 days.
Days 1 to 5:
Ondansetron and dexamethasone can be taken at same time as Temozolomide
 Ondansetron 16 mg PO pre Temozolomide
 Dexamethasone 8 mg PO pre Temozolomide
 Atropine 0.4 SC pre Irinotecan PRN if patient has experienced early diarrhea and
abdominal cramps with previous treatments
 Other:
 Other:
Day 8:
 No antiemetic required
 Other:

Treatment – Prescribed in order of administration All orders to be carried out must be checked and completed. Tick “Omit” to exclude

 Temozolomide
 125 mg/m2 = ………… mg PO daily (Cycle 1)
 150 mg/m2 = ………… mg PO daily (As of cycle 2 if no
previous grade 3 toxicity)
 Dose modification: ………… mg/m2 = ………… mg daily
 Omit
Dispensed dose: ………… mg PO daily
For 5 days on days 1 to 5
Round to nearest 5 mg. Available in capsules of 5 mg, 20 mg, 100 mg and 250 mg.
To be taken preferably on an empty stomach.
To be dispensed on a daily basis by Oncology pharmacy and to be administered by nurse.
Comments:

 Vincristine 1.5 mg/m2 = ………… mg IV (max: 2 mg) Day 1

 Dose modification: ………… mg/m2 = ………… IV (max : 2 mg)

 Omit
On days 1 and 8 Day 8
In 50 mL NS over 15 to 30 minutes
Comment:

Nom en lettres moulées N° Permis Heure/ Time Date

Signature
Name in print License No 00:00 AAYY/MM/JD
Médecin

Imprimé par le service REV ( ) Approbation P&T (2023-04-11)

 Physician

*FMU-2150*
Pharmacie
Temozolomide/Irinotecan/Vincristine
Pharmacy
Relapsed/refractory rhabdomyosarcoma Page 2 of 2
q 3 weeks cycle
CODE: Temozolomide_Irino_Vincrisitine (S)
Treatment – Prescribed in order of administration All orders to be carried out must be checked and completed. Tick “Omit” to exclude

TO BE GIVEN 1 HOUR AFTER TEMOZOLOMIDE:

 Irinotecan 50 mg/m2 = ………… mg IV daily
 Dose modification: ………… mg/m2 = ………… mg IV daily
 Omit
For 5 days on days 1 to 5
In 250 mL D5W over 60 minutes
Comment:
 Other/comment:
Post-treatment Tick checkbox to include
Days 1 to 5:
 Atropine 0.4 mg SC PRN if early diarrhea or abdominal cramps
 Other:
Post-chemotherapy medications Untick checkbox to strike out
 Dexamethasone 8 mg PO daily for 2 days starting on day 6
 Prochlorperazine 10 mg PO/PR q 4h PRN
 Loperamide 4 mg PO at onset of diarrhea, then 2 mg PO q 2h until no diarrhea
for 12h (4 mg PO q 4h during the night)
 Other:
Nom en lettres moulées N° Permis Heure/ Time Date
Signature
Name in print License No 00:00 AAYY/MM/JD
Médecin
Physician
Day 1: Nom en lettres moulées et/ou numéro de permis Initiales / Heure/ Time Date
AAYY/MM/JD Name in print and/or License number Initials 00:00 AAYY/MM/JD
Pharmacien(ne)
Pharmacist
Infirmier(ère)
Nurse
Day 2: Nom en lettres moulées et/ou numéro de permis Initiales / Heure/ Time Date
AAYY/MM/JD Name in print and/or License number Initials 00:00 AAYY/MM/JD
Infirmier(ère)
Nurse
Day 3: Nom en lettres moulées et/ou numéro de permis Initiales / Heure/ Time Date
AAYY/MM/JD Name in print and/or License number Initials 00:00 AAYY/MM/JD
Infirmier(ère)
Nurse
Day 4: Nom en lettres moulées et/ou numéro de permis Initiales / Heure/ Time Date
AAYY/MM/JD Name in print and/or License number Initials 00:00 AAYY/MM/JD
Infirmier(ère)
Nurse
Day 5: Nom en lettres moulées et/ou numéro de permis Initiales / Heure/ Time Date
AAYY/MM/JD Name in print and/or License number Initials 00:00 AAYY/MM/JD
Infirmier(ère)
Nurse
Day 8: Nom en lettres moulées et/ou numéro de permis Initiales / Heure/ Time Date
AAYY/MM/JD Name in print and/or License number Initials 00:00 AAYY/MM/JD
Pharmacien(ne)
Pharmacist
Imprimé par le service REV ( ) Approbation P&T (2023-04-11)
 Infirmier(ère)
Nurse

Imprimé par le service REV ( ) Approbation P&T (2023-04-11)