Lanthanum Carbonate Hydrate (Fosrenol®)
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
Management of hyperphosphataemia in a patient with chronic kidney disease on dialysis whose serum phosphate is not controlled on calcium and where:
(a) serum phosphate is greater than 1.6.mmol per L; or
(b) the serum calcium times phosphate product is greater than 4.0 at the commencement of therapy.
Management includes initiation, stabilisation and review of therapy as required.
Note: Not to be used in combination with Sevelamer
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
May 2009