Category Acute Care: Clinical Care Pharmacy

Name of Policy Chemotherapy Use and Prescribing Guidelines

Date Effective April 1997
Date Last Reviewed August 2004
Reviewing Director Assistant Director of Medical & Surgical Services

Purpose:
The purpose is to provide standard guidelines for the prescribing and provision of chemotherapy.

Applicable Locations:
Ambulatory Care Chemotherapy
Central Inpatient IV Room
Clinical Care Pediatrics

Policy:
A. Chemotherapy is defined as any agent with antineoplastic properties, with the exception of oral
antineoplastics that are taken chronically.

B. Chemotherapy is only dispensed for administration in a UNC Hospitals and Clinic environment by
the Pharmacy Department pursuant to complete orders written by an authorized prescriber
(Prescriptions for home use are not covered by this policy).

Procedure:
A. All chemotherapy orders must be signed by a UNC Hospitals authorized prescriber prior to
execution of the order.

1. Only attending physicians and authorized fellows may prescribe chemotherapy.

Each department chair or division chief will provide a list of those authorized to
prescribe chemotherapy to the Director of Pharmacy. The list will include each
prescriber’s name, number, and pager. The list will be updated each July and
maintained in chemotherapy admixture pharmacies.

B. All orders for chemotherapy must be written on a UNC Hospitals chemotherapy order form
approved by the Medical Records Committee. Blank and regimen-specific online forms are
available at
http://www.unch.unc.edu/pharmacy/chemo/protocols_chemo/adultchemofrmBlank.pdf
All patient information needed to assess appropriateness of orders is included on the
chemotherapy order form.

1. Required Information: The indication height, weight, and body surface area must
be included on the chemotherapy order form. If targeted area under the curve
(AUC) is used to calculate a dose of antineoplastic, the patient’s estimated or
actual creatinine clearance is included on the chemotherapy form with the
formula used to estimate clearance.

Exception: Adult intrathecal methotrexate and cytarabine and chemoembolization orders

do not require this information.

2. The name and number of active research protocols or the name of the standard
regimen is indicated on the order form. Copies of active research protocols and
their amendments are made available to nursing and pharmacy staff by
prescribers and are kept in the pharmacy and patient care units. If patients are
treated off of active research protocols or standard regimens, supportive
literature is provided and placed in the patient’s medical record. In the absence
of available literature, approval of the Division Chair is required prior to order
execution.

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 Category Acute Care: Clinical Care Pharmacy
Name of Policy Chemotherapy Use and Prescribing Guidelines
Date Effective April 1997
Date Last Reviewed August 2004
Reviewing Director Assistant Director of Medical & Surgical Services

3. The antineoplastic agent is prescribed by generic name. Any abbreviations or

variations from the generic name are not be accepted.

4. All antineoplastic doses are specified per unit body surface area, per unit body
weight or AUC when applicable. Modifications of a protocol/standard dose are
specified on the chemotherapy order form. The final dose to be administered is
provided on the chemotherapy form. All orders will use a standard format
including dose/BSA, dose/kg, or AUC/day. In the case of an antineoplastic
administered multiple times on a day, the format is dose/BSA or dose/kg.

5. All pertinent laboratory data for the regimen is available to pharmacy and nursing
and is reviewed prior to order execution.

6. The start date, frequency of administration and the number of days of

administration are indicated.

7. All antineoplastic orders specify the route of administration and infusion time (or
IV push) for intravenous administration.

C. The pharmacist responsible for screening the chemotherapy order and the nurse administering
the chemotherapy confirm the regimen/protocol dose and recalculate the patient dose based on
the parameters written on the order form. The screening pharmacist and the treatment nurse
sign the bottom of the chemotherapy order when final dosage checks and calculations have been
verified.

D. Compatible antineoplastics are physically admixed together if the administration rate and day of
administration are the same. The physician may request an admixture or the pharmacist may at
his/her discretion admix agents with documented physical and chemical compatibility. If a
dilution is not specified on an order, a standard dilution based on known compatibility data will
be used by the pharmacy.

E. Corrections or changes to original chemotherapy orders must be written on a new chemotherapy

order form. Verbal orders for corrections or changes to antineoplastics are not accepted.
Subsequent changes to administration times, rates of infusion and admixture that do not affect
the drug or total dose given may be written on standard order forms.

F. Records of chemotherapy ordered and dispensed will be maintained for a period of 2 years then
shredded.

Responsible Unit:
Clinical Care Service Pharmacist

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 Category Acute Care: Clinical Care Pharmacy
Name of Policy Chemotherapy Use and Prescribing Guidelines
Date Effective April 1997
Date Last Reviewed August 2004
Reviewing Director Assistant Director of Medical & Surgical Services

Approved By:

Assistant Director of Pharmacy Date

Director of Pharmacy Date

Chair, P & T Committee Date

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