Interferon Alfa-2b (Intron A®)
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.
CAUTION: Treatment with interferon alfa has been associated with depression and suicide in some patients. Patients with a history of suicidal ideation or depressive illness should be warned of the risks. Psychiatric status during therapy should be monitored.
Criteria
Patients with chronic hepatitis B who satisfy all of the following criteria:
- Histological evidence of chronic hepatitis on liver biopsy (except in patients with
coagulation disorders considered severe enough to prevent liver biopsy) - (a) Abnormal serum ALT levels in conjunction with documented chronic hepatitis B infection
or
(b) Elevated HBV DNA levels in conjunction with documented chronic hepatitis B infection - Are not 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)
- Female patients of child-bearing age are not pregnant, not breast-feeding, and are using an effective form of contraception.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
July 2008