Example orders for Pemetrexed (Alimta) in non-small cell lung cancer

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.

Pemetrexed (Alimta)

Original references may be found at Pemetrexed (Alimta)

Example regimen #1

• Pemetrexed (Alimta) 500 mg/m² IV on day 1
  • Administer over 10 minutes.

21-day cycles

Supportive therapy

• Ondansetron (Zofran) 8 mg IV 30 minutes prior to chemotherapy
• Lorazepam (Ativan) 0.5 mg PO x 1 prn nausea/anxiety
• Prochlorperazine (Compazine) 10 mg PO x 1 prn nausea
• Dexamethasone (Decadron) 4 mg PO twice per day the day before, day of, and day after chemotherapy
• Cyanocobalamin (Vitamin B12) 1000 mcg IM every 9 weeks, the first dose given at least 1 week prior to start of pemetrexed therapy
• Folic acid 1000 mcg PO daily, to start at least 1 week prior to start of pemetrexed therapy, to continue throughout therapy with pemetrexed

Hydration:

• 500 ml NS and/or D5W at KVO rate as running IV for chemotherapy infusion. Give up to 500 ml NS and/or D5W as needed for IV compatibility.

Monitoring:

• On day 1 of each cycle: CBC with differential, absolute neutrophil count (ANC), BUN/Cr, alk phos, AST, ALT, total bilirubin, albumin, carcinoembryonic antigen
  • Depending on provider preference and patient's tolerance, may simplify to CBC with differential, absolute neutrophil count (ANC), with less frequent BUN/Cr & LFT checks
• On cycle 1 day 10, check nadir CBC with differential, absolute neutrophil count (ANC). Need for further nadir count checks to be determined by degree of cytopenias.
• Assess for response with CT scan every 3+ cycles depending on symptoms

Outpatient medications:

• Dexamethasone (Decadron) as described above
• Lorazepam (Ativan) 0.5 mg PO every 6 hours prn anxiety, insomnia, nausea
• Ondansetron (Zofran) 4 mg PO every 6 hours prn nausea
• Prochlorperazine (Compazine) 10 mg PO every 6 hours prn nausea
• Folic acid 1000 mcg PO daily as described above

Clinical scenario & comments:

• 60 year-old lady with stage IV adenocarcinoma of the lung, s/p treatment with first-line therapy for metastatic disease with Carboplatin (Paraplatin) & Pemetrexed (Alimta), with good response. Pemetrexed (Alimta) was used as a maintenance therapy in this setting.