Lenograstim (Granocyte®)
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
Patients with non-myeloid malignancies receiving marrow-ablative chemotherapy and subsequent peripheral blood progenitor cell or bone marrow transplantation
Patients being treated with aggressive chemotherapy with the intention of achieving a cure or substantial remission in:
-
acute lymphoblastic leukaemia
-
ewing's sarcoma
-
germ cell tumours
-
infants and children with CNS tumours
-
neuroblastoma
-
non-hodgkin's lymphoma (intermediate or high grade)
-
osteosarcoma
-
relapsed hodgkin's disease
-
rhabdomyosarcoma.
Patients with breast cancer receiving standard dose adjuvant chemotherapy and patients receiving first line chemotherapy for Hodgkin's disease:
- who have had a prior episode of febrile neutropenia or prolonged severe neutropenia (neutrophil count below 1 x 109 per litre), and
- for whom there is a 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.
Mobilisation of peripheral blood progenitor cells to facilitate harvest of such cells for reinfusion into patients with non-myeloid malignancies who have had myeloablative or myelosuppressive therapy.
Mobilisation of peripheral blood progenitor cells, in normal volunteers, for use in allogeneic transplantation to facilitate harvest of such cells in healthy donors.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
February 2002