Levodopa with Carbidopa (Duodopa®)
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 advanced Parkinson disease in a patient with severe disabling motor fluctuations not adequately controlled by oral therapy.
Treatment must be commenced in a hospital-based movement disorder clinic.
Note
Patients should have adequate cognitive function to manage administration with a portable continuous infusion pump.
A positive clinical response to Duodopa administered via a temporary nasoduodenal tube should be confirmed before a permanent percutaneous endoscopic gastronomy (PEG) tube is inserted.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
August 2011