Filgrastim (Neupogen®)
Highly Specialised Drugs Program Declaration Form*
| 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.
Criteria:
Tick box to indicate the criterion that applies
For use in a patient undergoing induction and consolidation therapy for acute myeloid leukaemia
Mobilisation of peripheral blood progenitor cells to facilitate harvest of such cells for autologous transplantation into a patient with non-myeloid malignancy who has had myeloablative or myelosuppressive therapy
Mobilisation of peripheral blood progenitor cells, in a normal volunteer, for use in allogeneic transplantation
A patient receiving marrow-ablative chemotherapy and subsequent bone marrow transplantation
A patient with non-myeloid malignancy receiving marrow-ablative chemotherapy and subsequent autologous peripheral blood progenitor cell transplantation
A patient with breast cancer receiving standard dose adjuvant chemotherapy who has had a prior episode of febrile neutropenia or prolonged severe neutropenia (neutrophil count below 1 x 109 per litre), and for whom there is clinical justification for wishing to continue therapy with the same drug combination, dosage and treatment schedule, and for whom a good response to treatment is anticipated providing chemotherapy can be delivered as planned
A patient receiving chemotherapy for B-cell chronic lymphocytic leukaemia with fludarabine and cyclophosphamide who has had a prior episode of febrile neutropenia or prolonged severe neutropenia (neutrophil count of less than 1,000 million cells per litre), and for whom there is clinical justification for wishing to continue therapy with the same drug combination, dosage and treatment schedule, and for whom a good response to treatment is anticipated providing chemotherapy can be delivered as planned
A patient receiving first line chemotherapy for Hodgkin's disease who has had a prior episode of febrile neutropenia or prolonged severe neutropenia (neutrophil count below 1 x 109 per litre), and for whom there is clinical justification for wishing to continue therapy with the same drug combination, dosage and treatment schedule, and for whom a good response to treatment is anticipated providing chemotherapy can be delivered as planned
A patient receiving chemotherapy for myeloma who has had a prior episode of febrile neutropenia, and for whom there is clinical justification for wishing to continue therapy with the same drug combination, dosage and treatment schedule, and for whom a good response to treatment is anticipated providing chemotherapy can be delivered as planned
A patient with severe chronic neutropenia (absolute neutrophil count of less than 1 x 109 cells per litre measured on three occasions, with readings at least two weeks apart, or evidence of neutrophil dysfunction, and, either having experienced a life threatening infectious episode requiring hospitalisation and treatment with intravenous antibiotics in the previous twelve months, or having recurrent clinically significant infections [a minimum of three in the previous twelve months])
A patient with chronic cyclic neutropenia (absolute neutrophil count of less than 0.5 x 109 cells per litre lasting for three days per cycle, measured over three separate cycles, and, either having experienced a life threatening infectious episode requiring hospitalisation and treatment with intravenous antibiotics, or having recurrent clinically significant infections [a minimum of three in the previous twelve months])
Patients being treated with aggressive chemotherapy with the intention of achieving a cure or substantial remission in:
a. acute lymphoblastic leukaemia; or
b. breast cancer (adjuvant chemotherapy with docetaxel in combination with an anthracycline and cyclophosphamide); or
c. germ cell tumours; or
d. infants and children with CNS tumours; or
e. neuroblastoma; or
f. non-Hodgkin's lymphoma (aggressive grades or low grade receiving an anthracycline containing regimen); or
g. relapsed Hodgkin's disease; or
h. sarcoma.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
October 2009