PLACE LABEL HERE
PROCRIT (epoetin)
ANEMIA MANAGEMENT
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Laboratory: Anemia Profile, if not already available this admission
2. Indication/Dose: Procrit (epoetin) is available in limited vials sizes; round to nearest vial size as below
ONE TIME DOSES ARE ONLY ALLOWED TO BE ORDERED BY A NEPHROLOGIST
 End Stage Renal Disease (with HGB < 10 g/dL) Must be ordered by a Nephrologist
 Limit of 30,000 units weekly, (exception if outpatient dialysis records indicate higher dose necessary)
 Hold Procrit dose for Hemoglobin > 11.
Choose Dose





Route
Procrit (epoetin) 2,000 units
Procrit (epoetin) 4,000 units
Procrit (epoetin) 8,000 units
Procrit (epoetin) 10,000 units
Procrit (epoetin) 20,000 units
SQ
Choose Frequency (MAX: 30,000 units per week)




every Mon-Wed-Fri (limit 10,000 units/dose)
every Tue-Thur-Sat (limit 10,000 units/dose)
twice weekly every _________ (limit 14,000 units/dose)
weekly every ______________ (limit 30,000 units/dose)

Chronic Kidney Disease: Pre-Dialysis (Stage III or IV) (HGB < 10 g/dL) Must be ordered by a Nephrologist
 Procrit (epoetin) 4,000 units
 Procrit (epoetin) 10,000 units
SQ
SQ
q 7 days
q 7 days
 Anemia from concomitant chemotherapy for nonmyeloid malignancies (HGB < 10 g/dL)
Must be ordered by Oncologist/Hematologist and the following MUST be met before dispensing:
 Pharmacist to confirm that the ordering physician is an ESI APPRISE Oncology Program enrolled provider
 Nurse to contirm that the ESA APPRISE Patient Education Acknowledgement Form (consent) has been
signed by patient and physician and a copy placed in the medical record and sent to Pharmacy.

 Procrit (epoetin) 40,000 units
 Procrit (epoetin) 10,000 units
SQ
SQ
Once weekly starting________________________________
Three times a week on Mon-Wed-Fri or  Tue-Thur-Sat

 Trauma (HGB < 10 g/dL) Must be ordered by a Trauma Surgeon
 If < 40 kg:
Procrit (epoetin) 20,000 units SQ once weekly

 If 41-99 kg:
Procrit (epoetin) 40,000 units SQ once weekly
 If > 100 kg:
Procrit (epoetin) 60,000 units SQ once weekly
 Transfusion NOT an option (HGB <8 g/dL with normal anemia profile) No physician speciality restriction
 If < 40 kg:
Procrit (epoetin) 20,000 units SQ once weekly

 If 41-99 kg:
Procrit (epoetin) 40,000 units SQ once weekly
 If > 100 kg:
Procrit (epoetin) 60,000 units SQ once weekly
 Continuation of prior therapy: No physician speciality restriction
Procrit (epoetin) ____________ units SQ every __________________________
3.
Nurse to give Procrit Medication Guide to patient for review and document in the medical record
4.
Iron Replacement:
 Ferrous Sulfate (iron) 325 mg po tid
 Ferrlicet (ferric gluconate)  62.5 mg  125 mg  250 mg IVPB x ____ doses
______________
Date
__________________
Time
*1-26579*
_________________________________
Physician Signature
FORM 1-26579 REV. 04/2014
WHITE: Medical Record
CANARY: Pharmacy
___________
PID Number
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