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

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Carboplatin (Paraplatin) & Pemetrexed (Alimta)

Original references may be found at Carboplatin (Paraplatin) & Pemetrexed (Alimta)

Example regimen #1

• Carboplatin (Paraplatin) AUC 5 IV on day 1
  • Infuse over 30-60 minutes.
• Pemetrexed (Alimta) 500 mg/m2 IV on day 1
  • Administer over 10 minutes. Administer after carboplatin.

21-day cycles x 6 cycles

Supportive medications:

• Ondansetron (Zofran) 8 mg IV 30 minutes prior to chemotherapy
• Lorazepam (Ativan) 0.5-1 mg PO/IV x 1 prn nausea/anxiety
• Prochlorperazine (Compazine) 10 mg PO x 1 prn nausea
• Dexamethasone (Decadron) 4 mg PO BID 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 as part of a basic metabolic panel, 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), BUN/Cr
• 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 after cycle 3

Outpatient medications:

• Dexamethasone (Decadron) as described above
• Lorazepam (Ativan) 0.5 mg PO Q6H prn anxiety, insomnia, nausea
• Ondansetron (Zofran) 4 mg PO Q6H prn nausea
• Prochlorperazine (Compazine) 10 mg PO Q6H prn nausea
• Folic acid 1000 mcg PO daily as described above
• Due to refractory nausea, in later cycles, we eventually added Aprepitant (Emend) 125 mg PO on day 1, 80 mg PO on days 2-3, and Dexamethasone (Decadron) use was extended to include day -1 through day 4

Clinical scenario & comments:

• 60 year-old lady with stage IV adenocarcinoma of the lung, treated with first-line therapy for metastatic disease. Our institution's standard order set uses Carboplatin (Paraplatin) at AUC 5. This is reasonable in my view; the patient also had a history of pelvic radiation and chemotherapy for an unrelated malignancy many years ago. This was subsequently followed by Pemetrexed (Alimta) maintenance therapy.