Entecavir Monohydrate 0.5mg
Highly Specialised Drugs Program Declaration Form*
| NOTE: This declaration form is for PBS-subsidised entecavir monohydrate 0.5mg tablets, there is a different indication and declaration form for PBS-subsidised entecavir monohydrate 1mg tablets. |
| Patient’s Name: | ____________________________________ |
| Medical Record Number: | ____________________________________ |
| Medicare Number: | ____________________________________ |
I certify that the above patient meets the Pharmaceutical Benefits Advisory Committee’s criteria for funding under Section 100 of the National Health Act, 1953.
| NOTE: PBS-subsidised entecavir monohydrate must be used as monotherapy. |
Criteria
Chronic hepatitis B in a patient without cirrhosis who satisfies all of the following criteria:
- Elevated HBV DNA levels - greater than 20,000 IU/mL (100,000 copies/mL) if HBeAG positive, or greater than 2,000 IU/ml (10,000 copies/mL) if HBeAG negative - in conjunction with documented chronic hepatitis B infection;
- Evidence of chronic liver injury as determined by:
(a) Confirmed elevated serum ALT; or
(b) Liver biopsy.
Chronic hepatitis B in a patient with cirrhosis who has detectable HBV DNA.
Persons with Child's class B or C cirrhosis (ascites, variceal bleeding, encephalopathy, albumin less than 30 g per L, bilirubin greater than 30 micromoles per L) should have their treatment discussed with a transplant unit prior to initiating therapy.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
March 2012