Filgrastim
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 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 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 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 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 congenital neutropenia (absolute neutrophil count of less than 100 million cells per litre measured on 3 occasions, with readings at least 2 weeks apart, and in whom a bone marrow examination has shown evidence of maturational arrest of the neutrophil lineage)
A patient with chronic cyclic neutropenia (absolute neutrophil count of less than 500 million cells per litre lasting for 3 days per cycle, measured over 3 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 3 in the previous 12 months])
A patient with inoperable Stage III, IVa or IVb squamous cell carcinoma of the oral cavity, larnyx, oropharynx or hypopharynx receiving neoadjuvant treatment with docetaxel in combination with cisplatin and fluorouracil who has had a prior epsiode 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. 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 lymphoma (aggressive grades; or low grade receiving an
anthracycline containing regimen); or
g. relapsed Hodgkin disease; or
h. sarcoma; or
i. Hodgkin disease (first-line chemotherapy with escalated BEACOPP).
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
March 2012