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# Chemotherapy Calculations

Key Points:

## 1 – Calculations based on metric system (height in cm and weight in kg)

2 – There are various formulas for calculating body surface area (BSA). For our class, please use the Mostellar (also called the New
England Journal method) equation:

## (square root of (height x weight / 3600))

3 – Know your own body weight, height, and BSA so that you can do the “eyeball” test with the patient who is in front of you to estimate
if a dose is reasonable

4 – Yes, you need to memorize the conversions to metric, the Cockcroft-Gault equation, and how to calculate absolute neutrophil count
(ANC); we will give you the formulas for BSA and carboplatin dosing

 2.54 cm = 1 inch
 1 kg = 2.2 pounds
 Carboplatin dose (mg) = Target AUC x (CrCl + 25) (this is the Calvert formula; there are various formulas used for
carboplatin dosing but this is the most commonly used. CrCl should be calculated using Cockcroft-Gault and capped at 125
mL/min)
 CrCl (mL/min) for men = (140 – age)(actual body weight) / (SCr)(72)
 CrCl (mL/min) for women = above x 0.85
 *In oncology, the American Society of Clinical Oncology (ASCO) has recommended that actual body weight be used even for
obese individuals with no capping of the dose. This is not necessarily true in other disease states but we follow ASCO
guidelines in oncology practice. When you are on clerkship and when you are a practicing pharmacist, you should check with
your institution regarding the standard method for CrCl estimation, both for oncology and non-oncology patients. In many
non-oncology settings, ideal body weight (IBW) is used for obese patients (those who weigh >30% of IBW)
 ANC (the units are “neutrophils”) = WBC x (segs% + bands%)

5 – for this class, provide exact dose and volume; in real life, you often will round to the nearest vial size for monoclonal antibodies and
other expensive drugs. The maximum dose for vincristine is 2 mg no matter the BSA. Round to the nearest whole number for mg, mL,
kg, cm, and absolute neutrophil count (ANC); round to 2 decimal places for BSA (measured in m2).

6 – You will be provided with package inserts or concentration of drug products so that you can calculate both a dose in mg and also the
volume in mL of the drug in question

7 – You will also need to do calculations with some of the oral therapies – for example, how many pills would you dispense when some
of these therapies require multiple pills/dose?

8 – You will be expected to do opioid conversions as well. We will cover this in more detail during the pain and constipation lecture.
You should not memorize these conversions. They will be provided to you and in practice, you should also double-check yourself to
make sure that you do not make an error.

9 – Please pay attention to units for safety. Please also note for safety reasons that documenting the dose in the chart should be written as
generic name of drug YY mg (XX mg/m2). For example, pemetrexed 1000 mg (500 mg/m2). A mg dose by itself does not allow us to
check the dosing of a regimen or protocol. Both the actual dose and the dose expected in mg/m2 should be provided.

10 – Doses should be rounded to whole numbers. For oral chemotherapy, round to nearest pill size, because these pills should not be
crushed/split/broken

11 – Chemotherapy is given in “cycles.” The most common chemotherapy “cycle” is 21 days. Sometimes multiple doses of
chemotherapy are given on different days in a cycle. For example, gemcitabine is often given on day 1, day 8, and day 15 every 28 days.
This means that the patient receives 3 doses per cycle. It is important to know how many doses of chemotherapy are given in a cycle.
The best source is the primary literature/clinical research study for the treatment regimen, which is often referenced in the NCCN
guidelines. You will be asked to calculate the number of milligrams a patient receives per dose and per cycle. In the adjuvant setting
(chemotherapy given after surgery or radiation), a defined numbers of cycles is given to a patient, often 4 – 6 cycles. When the patient
completes all 4 -6 cycles, the patient is said to have been treated with a “course” of chemotherapy. In the metastatic setting, when the
anticancer drugs are changed because the patient progresses, he begins a new “course” of treatment.
Examples:

1 – JJ is a 54 year-old woman who has been prescribed doxorubicin 60 mg/m2 IV day 1 every 21 days with cyclophosphamide 600
mg/m2 IV every 21 days for metastatic breast cancer. JJ is 5’4” and weighs 135 pounds. Doxorubicin is supplied as 10 mg/mL and is
given as an IV push and Cyclophosphamide is supplied as 20 mg/mL (after reconstitution). What dose in mg will JJ receive for each
drug? How many mL of each drug with JJ receive?

##  Height (cm) = 64 inches x 2.54 cm/inch = 162.56 cm = 163 cm

 Weight (kg) = 135 pounds / 2.2 kg/pound = 61.37 kg = 61 kg
 BSA (m2) = square root of [163 cm x 61 kg / 3600] = square root of [2.76] = 1.66 m2
 Doxorubicin 60 mg/m2 = 60 mg x 1.66 m2 = 99.6 mg = 100 mg
 Doxorubicin 100 mg / 10 mg/mL = 10 mL
 Cyclophosphamide 600 mg/m2 x 1.66 m2 = 996 mg
 Cyclophosphamide 996 mg / 20 mg/mL = 49.8 mL = 50 mL

2 – HG is a 73 year-old man who has been prescribed carboplatin AUC 5 IV every 21 days with paclitaxel 175 mg/m2 IV every 21 days
for Stage IV squamous cell non-small cell lung cancer. HG is 5’11” and weighs 180 pounds and his SCr is 1.1 mg/dL. Carboplatin is
supplied as 10 mg/mL (after reconstitution) and paclitaxel is supplied as 6 mg/mL.

##  Height (cm) = 71 inches x 2.54 = 180.34 cm = 180 cm

 Weight (kg) = 180 pounds / 2.2 kg/pound = 81.8 kg = 82 kg
 BSA (m2) = square root of [180 cm x 82 kg / 3600] = square root of [4.1] = 2.02 m2
 CrCl = (140 – age)(weight) / (SCr)(72) = (140 – 73)(82 kg) / (1.1 mg/dL)(72) = 69.37 mL/min = 69 mL/min
 Carbo dose in mg = (Target AUC)(CrCl + 25) = (5)(69 + 25) = 470 mg
 Carboplatin 470 mg / 10 mg/mL = 47 mL
 Paclitaxel 175 mg/m2 x 2.02 m2 = 353.5 mg = 354 mg
 Paclitaxel 354 mg / 6 mg/mL = 59 mL

3 – FM is a 64 year-old man who has been prescribed capecitabine 1250 mg/m2 PO q12hours days 1 – 14 every 21 days for metastatic
colorectal cancer. He is 6’2” and weighs 190 pounds today. Capecitabine is supplied as 150 mg and 500 mg tablets.

##  Height (cm) = 74 inches x 2.54 = 187.95 cm = 188 cm

 Weight (kg) = 190 pounds / 2.2 kg/pound = 86.36 kg = 86 kg
 BSA (m2) = square root of [188 cm x 86 kg / 3600] = square root of [4.49] = 2.1 m2
 Capecitabine 1250 mg/m2 x 2.1 m2 = 2625 mg/dose twice daily
 Capecitabine 2625 mg = (five 500 mg tablets + one 150 mg tablets) twice daily
 Dispense Ten 500 mg tablets/day x 14 days = #140 (500 mg tablets)
 Dispense two 150 mg tablets/day x 14 days = #28 (150 mg tablets)

Note: The formulas for carboplatin dosing and BSA will be provided to you on the exam. You will need to memorize metric conversions,
the Cockcroft-Gault equation, and how to calculate absolute neutrophil count (ANC). Use actual body weight in the Cockcroft-Gault
equation.

## BSA (m2) = square root of [(height)(weight)/3600]

1 inch = 2.54 cm

1 kg = 2.2 pounds

## ANC (neutrophils) = WBC x (segs% + bands%)

1 - MC is a 63 year-old male with grade 2 follicular lymphoma. He is 6’2” and weighs 172 pounds. All labs are within normal limits
(WNL). He is prescribed R-CHOP chemotherapy. What dose in mg of each drug in R-CHOP will the patient receive? What is the total
dose of prednisone that the patient will receive per dose? Per cycle? How many tablets per dose will the patient take (note that we try to
keep the pills uniform in strength and as few pills as possible, and in this case in oncology, rarely use less than 10 mg tablets).
Cyclophosphamide is available as a 1 gram power for injection per vial, which you dilute with 0.9% sodium chloride USP to 20 mg/mL.
How many vials of cyclophosphamide do you need to make MC’s dose? How many mL of cyclophosphamide will he receive?

## Vincristine 1.4 mg/m2 x 2.02 m2 (max 2 mg) = 2 mg

Oral prednisone 100 mg/m2 days 1 – 5 x 2.02 m2 = 202 mg/day = 200 mg (four 50 mg tablets)

## Cyclophosphamide 1515 mg/1000 mg/vial = 1.515 vials = 2 vials

2 – GB is a 29 year-old female with stage I Hodgkin’s lymphoma who will be treated with the ABVD (Adriamycin ® = doxorubicin;
bleomycin; vinblastine; dacarbazine) regimen. She is 5’5” and weighs 118 pounds. What dose in mg of each drug in ABVD will she
receive? GB returns for cycle 2 post 1 week of grade 3 mucositis, which requires a 50% dose-reduction of bleomycin and doxorubicin.
What will her new dose of these drugs be for cycle 2?

## (All given IV days 1 and 15 every 4 weeks)

3 – ML is a 48 year-old woman with stage II HER-, ER/PR+ breast cancer scheduled for adjuvant treatment with the AC (Adriamycin ®
= doxorubicin; cyclophosphamide). She is 5’7” and weighs 145 pounds. What is her dose of each drug in mg? Doxorubicin is supplied
as 10 mg/5mL solution for injection. How many mL of the solution will be needed to make her dose?

## (Each given every 21 days)

4 – SP is a 74 year-old woman with stage III ovarian cancer who is prescribed the paclitaxel/cisplatin IV/IP (intraperitoneal) regimen.
She is 5’0” tall and weighs 100 lbs. What is her dose in mg for each drug? On cycle 2, her SCr is 1.7 g/dL. Look up cisplatin in
Clinical Pharmacology; what should her new dose of cisplatin be given her new CrCl?

## BSA = square root of (152 cm x 45 kg / 3600) = 1.38 m2

Paclitaxel 135 mg/m2 IV CIVI (continuous intravenous infusion) over 24 hours day 1

## (all given every 3 weeks for 6 cycles)

5 – DM is a 58 year-old male with stage IV bladder cancer who will be treated with DD-MVAC (dose-dense MVAC or methotrexate,
vinblastine, doxorubicin (Adriamycin®), cisplatin). He is 6’3” tall and weighs 210 pounds. What is the dose in mg of each drug? On
cycle 2, DM’s SCr is 2.1 g/dL. Look up each drug in Clinical Pharmacology; what should the dose of each drug be for cycle 2 given
DM’s new CrCl?

## 210 pounds / 2.2 kg/pound = 95.45 kg = 95 kg

BSA = square root of (191 cm x 95 kg / 3600) = 2.25 m2 (note new ASCO recommendations are to not cap doses at BSA of 2 m2)

## Cisplatin 70 mg/m2 IV day 2 x 2.25 m2 = 157.5 mg = 158 mg

Pegfilgrastim 6 mg SC day 3 = 6 mg

## CrCl = (140 – 58)(95 kg)/(72)(2.1 g/dL) = 51.5 mL/min = 52 mL/min

Cisplatin: decrease dose 25% (which means administer 75% of the dose) for CrCl 45 – 60 mL/min: 158 mg x 0.75 = 118.118.5 mg =
119 mg

Methotrexate: administer 65% of the standard dose for CrCl 46-60 mL/min: 68 mg x 0.65 = 44.2 mg = 44 mg

6 – Cl is a 67 year-old male with stage IIb nonsquamous cell non-small cell lung cancer (NSCLC) who is prescribed adjuvant paclitaxel
and carboplatin with concurrent radiation therapy (RT). He is 5’11” tall and weighs 182 pounds, and his SCr today is 0.8 g/dL. What is
the dose in mg for each drug?

## Carboplatin AUC 6 IV every 21 days = (6)(105 mL/min + 25) = 780 mg

7 – DV is a 62 year-old male with stage IV pancreatic cancer who will be treated with 4 cycles of gemcitabine and albumin-bound
paclitaxel (nab-paclitaxel or Abraxane ®). He is 6 feet 1 inch tall and weights 220 pounds. What is his dose in mg for each drug? How
many mg of gemcitabine will DV receive per cycle?

## BSA = square root of (185 cm x 100 kg / 3600) = 2.27 m2

Gemcitabine 1000 mg/m2 IV days 1, 8, 15 every 28 days x 2.27 m2 = 2270 mg/day x 3 doses/cycle = 6810 mg

Albumin-bound paclitaxel 125 mg/m2 IV day 1 every 28 days x 2.27 m2 = 283.75 mg = 284 mg

8 – GH is a 56 year-old male with stage IV HER2+ gastric carcinoma (yes, stomach cancers can over-express HER2 just like breast
cancer!) who will be treated with trastuzumab, cisplatin, and fluorouracil (5FU). He is 6 feet 2 inches tall and weighs 195 lbs. What is
the dose in mg that GH will receive of each drug each day? What is the dose in mg of fluorouracil that GH will receive per cycle?

## 1728 mg/day x 5 days = 8640 mg/cycle

9 – GH fails the trastuzumab, cisplatin, and fluorouracil regimen and is now on second-line ramucirumab and paclitaxel. How many mg
of each drug will GH receive? Ramucirumab is administered over 60 minutes. Unfortunately, GH experiences a grade 2 infusion
reaction 15 minutes into the infusion of ramucirumab. How many mg of ramucirumab did GH receive before the infusion was stopped?
The nurses stopped the infusion, administered diphenhydramine, and the patient recovered. Look up ramucirumab in Clinical
Pharmacology; how should the ramucirumab dose or rate be changed for cycle 2? Please write the new order.

## 712 mg/60 minutes = 11.9 mg/minute = 12 mg/minute x 15 minutes = 180 mg

Grade 1-2 infusion reactions require a 50% rate reduction. 8 mg/kg over 60 minutes x 0.5 = 8 mg/kg over (60 + 30 minutes) = 90
minutes.
10 – LK is a 72 year-old man who presents to clinic for cycle 4 of cabazitaxel 25 mg/m2 IV for his stage IV castration-resistant prostate
cancer (CRPC). He reports having a fever of 100 degrees F for the last 3 days. His complete blood count (CBC) with differential is:

##  CBC with differential

 WBC: 17,900 cells/mm3
 WBC differential
 -Segs: 65%
 -Bands: 10%
 -Lymphocytes: 17%
 -Monocytes: 5%
 -Eosinophils: 2%
 -Basophils: 0.5 %
 RBC: 4.2 × 106 cells/mm3
 Hgb: 14 g/dL
 Hct: 42%
 MCV: 90 μm3/cell
 MCH: 31 pg/cell
 MCHC: 36 g/dL

## ANC = (17,900)(0.65+0.10) = 13,425 neutrophils/mL

11 – LK’s chemotherapy is held and he is treated with a course of antibiotics. 3 weeks later, he presents to clinic for evaluation of
continued treatment with cabazitaxel. He is cleared for chemotherapy and receives 2 more cycles. On cycle 6, LK presents with the
following labs:

## Na 135 mEq/L WBC 3100/mm3 AST 16 IU/L

K 3.6 mEq/L Segs 14% ALT 15 IU/L
Cl 95 mEq/L Bands 5% Alk phos 38 IU/L
CO2 21 mEq/L Lymphs 81% LDH 187 IU/L
BUN 16 mg/dL Hgb 8.9 g/dL T. bili 0.6 mg/dL
SCr 1.0 mg/dL Hct 25.3%
Glu 149 mg/dL RBC 2.6 × 106/mm3
Ca 8.0 mg/dL Plt 21 × 103/mm3

## ANC = (3100)(0.14+ 0.05) = 589 neutrophils/mL

NO, LK does not meet the requirement to have ANC of at least 1500 nuetrophils/mL to safely receive chemotherapy. He should NOT be
treated today.
12 – TM is a 67 year-old woman who has been prescribed cisplatin 75 mg/m2 IV day 1 every 21 days with pemetrexed 500 mg/m2 IV
day 1 every 21 days for stage IV adenocarcinoma non-small cell lung cancer. TM is 5’5” and weighs 126 pounds. Cisplatin is supplied
as 1 mg/mL and pemetrexed is supplied as 25 mg/mL. What dose in mg will TM receive for each drug? How many mL of each drug
with TM receive? Unfortunately TM experiences grade 3 diarrhea following cycle 1. Using the information from the pemetrexed
package insert (http://pi.lilly.com/us/alimta-pi.pdf) , what should TM’s new doses of pemetrexed and cisplatin be (once her oncologist
determines it is safe to re-start chemotherapy)?

##  65 inches x 2.54 cm/inch = 165.1 cm = 165 cm

 126 pounds / 2.2 kg/pound = 57.3 kg = 57 kg
 BSA = square root of (165 cm x 57 kg / 3600) = square root of 2.6125 = 1.62 m=2
 Cisplatin 75 mg/m2 x 1.62 m2 = 121.5 mg = 122 mg
 Cisplatin 1 mg/mL x 122 mg = 122 mL
 Pemetrexed 500 mg/m2 x 1.62 m2 = 810 mg
 Grade 3 nonhematologic toxicity requires giving 75% of previous dose for both drugs
 Cisplatin 122 mg x 0.75 = 91.5 mg = 92 mg
 Pemetrexed 810 mg x 0.75 = 607.5 mg = 608 mg

13 – YT is a 75 year-old man who has been prescribed carboplatin AUC 2 IV weekly in combination with daily radiation therapy for his
locoregional cancer of oropharynx. YT is 6’1” and weighs 185 pounds and his SCr is 0.9 mg/dL. Carboplatin is supplied as 10 mg/mL
(after reconstitution). What dose of carboplatin will YT receive and how many mL of the reconstituted drug will be needed for this
dose?

##  73 inches x 2.54 cm/inch = 185.42 cm = 185 cm

 185 pounds / 2.2 kg/pound = 84 kg
 CrCL = (140-75)(84 kg) / (72)(0.9) = 84.26 mL/min = 84 mL/min
 Carboplatin dose (mg) = Target AUC x (CrCl + 25) = 2(84 + 25) = 218 mg
 Carboplatin 218 mg / 10 mg/mL = 21.8 mL = 22 mL

14 – SR is a 53 year-old woman who has been prescribed capecitabine 1000 mg/m2 PO q12hours days 1 – 14 every 21 days with
lapatinib 1250 mg PO daily for recurrent HER2+ metastatic breast cancer. She is 5’2” and weighs 110 pounds. Capecitabine is supplied
as 150 mg and 500 mg tablets. What dose in mg will SR receive? Describe the number and strength of capecitabine pills that will be the
closest to providing this dose. At her first follow-up appointment, it is discovered that SR’s CrCl is 45 mL/min. Using the information
from the package insert (http://www.gene.com/download/pdf/xeloda_prescribing.pdf), what should the new dose and pill regimen be for
SR? Note, capecitabine is not FDA-approved for use in combination with lapatinib, however, this is a common and recommended drug
therapy option for patients with this disease after failure of a trastuzumab regimen. Please follow dose-adjustment recommendations as
outlined in the package insert as if the drug were used in combination with docetaxel.

##  62 inches x 2.54 cm/inch = 157.48 cm = 157 cm

 110 pounds / 2.2 kg/pound = 50 kg
 BSA = square root of (157 cm x 50 kg / 3600) = square root of (2.18) = 1.48 m2
 Capecitabine 1000 mg/m2 x 1.48 m2 = 1480 mg/dose = 2960 mg total daily dose
 Three 500 mg tablets/dose is most reasonable = 3000 mg total daily dose
 75% of starting dose required for CrCl = 30-50 mL/min
 capecitabine 1000 mg/m2 x 0.75 = 750 mg/m2
 750 mg/m2 x 1.48 m2 = 1110 mg/dose x 2 = 2220 mg total daily dose
 Two 500 mg tablets in the AM and two 500 mg tablets in the PM with one 150 mg tablet in PM closest to expected dose
15 – HN is a 72 year-old male scheduled to receive his first dose of cabazitaxel 25 mg/m2 IV day 1 every 21 days for castrate-resistant
metastatic prostate cancer. He is 5’9” tall and weighs 175 pounds. Cabazitaxel is supplied as 10 mg/mL (after first dilution). What dose
in mg will HN receive and how many mL of reconstituted cabazitaxel is needed to provide this dose?

##  69 inches x 2.54 cm/inch = 175.26 cm = 175 cm

 175 pounds / 2.2 kg/pound = 79.5 kg = 80 kg
 BSA = square root of (175 x 80 / 3600) = square root of 3.89 = 1.97 m2
 Cabazitaxel 25 mg/m2 x 1.97 m2 = 49.25 mg = 49 mg
 Cabazitaxel 49 mg / 10 mg/mL = 4.9 mL

16 – MK is a 62 year-old woman who is about to be treatment with modified FOLFOX6 with bevacizumab for stage IV colorectal
cancer. She is 5’6” tall and weighs 150 pounds. What is the dose in mg and the volume in mL of reconstituted drug that MK should
receive of fluorouracil bolus, fluorouracil 46-hour infusion, leucovorin, oxaliplatin, and bevacizumab? For the 46-hour fluorouracil dose,
please provide the dose per day and the total dose that will be needed for the duration of the 46 hours. Doses can be found in the NCCN
colorectal cancer guidelines v.2.2015 on page 30/143 of the pdf, from: http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf.
because new drugs and regimens are added to the guidelines on a regular basis and it is always best to look up the guidelines to verify the
doses.) The drugs are supplied (after reconstitution) as the following:

## Fluorouracil 1.5 mg/mL

Leucovorin 20 mg/mL

Oxaliplatin 5 mg/mL

##  66 inches x 2.54 cm/inch = 167.64 cm = 168 cm

 150 pounds / 2.2 kg/pound = 68.2 kg = 68 kg
 BSA = square root of (168 cm x 68 kg / 3600) = square root of 3.17 = 1.78 m2
 Fluorouracil 400 mg/m2 bolus x 1.78 m2 = 712 mg
 Fluorouracil 712 mg / 1.5 mg/mL = 474.67 mL = 475 mL
 Fluoruracil 1200 mg/m2/day x 1.78 m2 = 2136 mg/day x 2 days = 4272 mg/course
 Fluroruracil 2136 mg / 1.5 mg/mL = 1424 mL/day x 2 – 2848 mL/course (patients are sent home on a pump with the full
course of treatment in one bag. They return after 46 hours to have the IV bag and pump removed)
 Leucovorin 400 mg/m2 x 1.78 m2 = 712 mg
 Leucovorin 712 mg / 20 mg/mL = 35.6 mL = 36 mL
 Oxaliplatin 85 mg/m2 x 1.78 m2 = 151 mg.
Oxaliplatin 146 mg / 5 mg/mL = 30 mL
 Bevacizumab 5 mg/kg x 68 kg = 340 mg
 Bevacizumab 340 mg / 100 mg/4 mL = 13.6 mL = 14 mL

17 – LL is a 60 year-old woman who is about to receive ado-trastuzumab emtansine 3.6 mg/kg IV day 1 every 21 days for recurrent
HER2+ metastatic breast cancer. She is 5’1” tall and weighs 125 pounds. Ado-trastuzumab emtansine is supplied as 20 mg/mL after
dilution. What is the dose in mg and volume in mL that LL will receive? At cycle 3, it is discovered that LL’s serum AST has increased
what should LL’s new dose and volume of ado-trastuzumab be?

##  61 inches x 2.54 cm/inch = 154.9 cm = 155 cm

 125 pounds / 2.2 kg/pound = 56.8 kg = 57 kg
 Ado-traz 3.6 mg/kg x 57 kg = 205.2 mg = 205 mg
 Ado-traz 205 mg / 20 mg/mL = 10.25 mL = 10 mL
 Reduce one dose level for AST/ALT 5-20x ULN (after resolves to less than 5xULN) = 3 mg/kg ado-traz
 Ado-traz 3 mg/kg x 57 kg = 171 mg
 Ado traz 171 mg / 20 mg/mL = 8.55 mL = 9 mL
18 – LP is a 68 year-old man who is scheduled to receive FOLFIRI with cetuximab for his stage IV colorectal cancer. He is 5’11” and
weighs 220 pounds. What is the dose in mg and the volume in mL of reconstituted drug that MK should receive of fluorouracil bolus,
fluorouracil 46-hour infusion, leucovorin, irinotecan, and cetuximab (use 400 mg/m2 for the day 1 dosing of cetuximab)? For the 46-hour
fluorouracil dose, please provide the dose per day and the total dose that will be needed for the duration of the 46 hours. Doses can be
found in the NCCN colorectal cancer guidelines v.2.2015 on page 31/143 of the pdf, from:
guidelines! This will be important for you once you are practicing because new drugs and regimens are added to the guidelines on a
regular basis and it is always best to look up the guidelines to verify the doses.) The drugs are supplied (after reconstitution) as the
following:

## Fluorouracil 1.5 mg/mL

Leucovorin 20 mg/mL

Irinotecan 20 mg/mL

Cetuximab 2 mg/mL

##  71 inches x 2.54 cm/inch = 180 cm

 220 pounds / 2.2 kg/pound = 100 kg
 BSA = square root of (180 cm x 100 kg / 3600) = square root of 5 = 2.24 m2
 Fluorouracil 400 mg/m2 bolus x 2.24 m2 = 896 mg
 Fluoruracil 896 mg / 1.5 mg/mL = 597 mL
 Fluorouracil 1200 mg/m2/day x 2.24 m2 = 2688 mg/day x 2 = 5376 mg/course
 Fluorouracil 2688 mg / 1.5 mg/mL = 1792 mL/day = 3584 mL/course (this is what would actually be made an put into the bag
because the patient is sent home for 2 days with one bag connected to a pump)
 Leucovorin 400 mg/m2 x 2.24 m2 = 896 mg
 Leucovorin 896 mg / 20mg/mL = 44.8 mL = 45 mL
 Irinotecan 180 mg/m2 x 2.24 m2 = 403.2 mg = 403 mg
 Irinotecan 403 mg / 20 mg/mL = 20.2 mL = 20 mL
 Cetuximab 400 mg/m2 x 2.24 m2 = 896 mg
 Cetuximab 896 mg / 2 mg/mL = 448 mL

19 – WR is a 54 year-old man diagnosed with stage III esophageal carcinoma who had surgery and is now scheduled to receive adjuvant
chemotherapy with fluoruracil 800 mg/m2 continuous intravenous infusion (CIVI) over 24 hours daily days 1-5 every 28 days with
cisplatin 100 mg/m2 IV day 1 every 28 days for 3 cycles. WR is 5’8” tall and weighs 150 pounds. What is the dose and volume of
fluorouracil that WR will receive each day and the total dose and volume that he will receive after 5 days? What is the dose and volume
of cisplatin that WR will receive on day 1 of each cycle? Fluorouracil is supplied as 1.5 mg/mL after reconstitution and cisplatin is
supplied as 1 mg/mL after reconstitution.

##  68 inches x 2.54 cm/inch = 172.7 cm = 173 cm

 150 pounds / 2.2 kg/pound = 68 kg
 BSA = square root of (173 cm x 68 kg / 3600) = square root of (3.27) = 1.81 m2
 Fluorouracil 800 mg/m2 /day x 1.81 m2 = 1448 mg/day x 5 days = 7240 mg/course
 Fluorouracil 1448 mg / 1.5 mg/mL = 965 mL/day x 5 days = 4827 mL/course (the patient is sent home with the drug for all 5
days in one bag that is administered via a pump set at the rate to administer the correct dose/min)
 Cisplatin 100 mg/m2 x 1.81 m2 = 181 mg
 Cisplatin 181 mg / 1 mg/mL = 181 mL
20 – HG is a 24 year-old male diagnosed with stage III testicular cancer who is scheduled to receive bleomycin, etoposide, and cisplatin
(the BEP regimen). He is 6’2” tall and weighs 195 pounds. The dose and schedule of the drugs in this regimen can be found on page
29/59 of the NCCN practice guideline for testicular case v.1.2015 available at
http://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf. What is the dose in mg and volume in mL that HG will receive of
etoposide and cisplatin each day and in total at the end of the 5 days of the regimen? What is the dose in units and volume in mL that
HG will receive of bleomycin on day 1 of this regimen? Cisplatin is supplied as 1 mg/mL (after reconstitution), etoposide as 20 mg/mL
(no reconstitution needed), and bleomycin as 5 units/mL (after reconstitution).

##  74 inches x 2.54 cm/inch = 188 cm

 195 pounds / 2.2 pounds/kg = 88.6 kg = 89 kg
 BSA = square root of (188 cm x 89 kg / 3600) = square root of 4.65 = 2.2 m2
 Etoposide 100 mg/m2/day x 2.2 m2 = 220 mg/day x 5 days = 1100 mg/course
 Etoposide 220 mg / 20 mg/mL = 11 mL (unlike the fluorouracil problems above, etoposide is not administered as a CIVI; the
patient comes in each day to receive the dose)
 Cisplatin 20 mg/m2/day x 2.2 m2 = 44 mg/day x 5 days = 220 mg/course
 Cisplatin 44 mg / 1 mg/mL = 44 mL/dose (unlike the fluorouracil problems above, cisplatin is not administered as a CIVI; the
patient comes in each day to receive the dose)
 Bleomycin 30 units IV weekly = this is a flat dose so the patient receives 30 units regardless of weight or BSA
 Bleomycin 30 units / 5 units/mL = 6 mL

21 – BN is a 55 year-old man diagnosed with metastatic melanoma with BRAF V600E mutation who is prescribed vemurafenib
(Zelboraf ®) 960 mg PO q12hours every day. Vemurafenib is available as 240 mg tablets. How many tablets will the patient take for
each dose, for each day, and for a 30-month supply? After 3 weeks, BN experiences a grade 3 rash. Using the package insert
(http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/202429s005lbl.pdf), what should BN’s new dose of vemurafenib be once his
rash resolves to less than grade 2? How many tablets will constitute this new dose for each administration, each day, and for a 30-month
supply?

Vemurafenib 960 mg/dose / 240 mg/tablet = 4 tablets/dose x 2 doses/day = 8 tablets/day x 30 days = 240 tablets/30 days.
 After first appearance of a grade 3 adverse event, reduce dose to 720 mg po q12hours
 720 mg / 240 mg/tablet = 3 tablets/dose x 2 doses/day = 6 tablets/day x 30 days = 180 tablets/30 days