This is the text extract for SA0473 - Imiglucerase (Cerezyme) therapy - renewal application, browse documents here.

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Renewal application for imiglucerase (Cerezyme) therapy

Send completed applications to: Gaucher Panel Co-ordinator PHARMAC P O Box 10-254 WELLINGTON Fax: (04) 460 4995 Phone: (04) 460 4990 Email: gaucherpanel@pharmac.govt.nz

Date of Application:

_________________________________________

Patient Name: NHI number:

_________________________________________

Date of Birth:

_______/_______/_______

1. Physical examination: Date:___________________

Weight (kg) Height (cm) If child, please attach height chart Pulse Blood pressure Spleen - cm below costal margin Liver - cm below costal margin

2. Bloods

Notes: New patients require 3-monthly tests Patients with stable disease require annual tests.

Date Hb Platelets Chito. / hr Chito. / min

P60-6-1 #23339

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3. Radiology

NB: MRI imaging must include both CD and report New patients, and patients with unstable disease require an annual MRI Patients with stable disease require MRI imaging every 2 - 5 years Date of MRI:

Abdomen: Liver volume and spleen volume Lumbar spine: Sagittal T1 & T2; Sagittal STIR Femora (whole bone): Coronal T1 & T2; Coronal STIR An attempt at calculation of bone marrow burden score (by Maas criteria) Other tests: (please specify)

CD Included

Report Included

4. Neurological

Comments:_______________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

5. Current medications

Imiglucerase Bisphosphonates Pain relief Other

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6. Current Symptoms / Wellbeing of patient over previous 12 months

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

7. Compliance

To the best of your knowledge patient is compliant with Cerezyme therapy The patient wishes to continue with Cerezyme therapy Do you consider that the patient continues to derive benefit from Cerezyme therapy? YES / NO YES / NO YES / NO

8. Checklist

Complete reports are attached

  

I acknowledge that this application, if approved will be valid for 12 months only and that I will have to reapply for ongoing therapy for this patient.

The patient acknowledges that if there is not sufficient response to therapy that subsidy for ongoing therapy may not be forthcoming.

Signed: ________________________________

Date: _____ / _____ / _______

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