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

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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.

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 to 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.