Lanreotide Acetate (Somatuline LA®)
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
Active acromegaly in patients with persistent elevation of mean growth hormone levels of greater than 2.5 micrograms/ Litre AND
(a) after failure of other therapy including dopamine agonists; OR
(b) as interim treatment in patients awaiting the effects of radiotherapy and where treatment with dopamine agonists has failed; OR
(c) if the patient is unfit for or unwilling to undergo surgery and where radiotherapy is contraindicated.
In a patient treated with radiotherapy. subsidisation through the HSD Program must cease if there is biochemical evidence of remission (normal IGF1) after lanreotide has been withdrawan for at least 4 weeks (6 weeks after the last dose). Lanreotide should be withdrawn every 2 years in the 10 years after radiotherapy for assessment of remission
Subsidisation through the HSD Program must cease if IGF1 is not lower after 3 months treatment.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
July 2007