This is the text extract for SA0643 – Imatinib mesylate for treatment of chronic myeloid leukaemia or gastrointestinal stromal tumour (GIST), browse documents here.

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CHRONIC MYELOID LEUKAEMIA TREATMENT APPLICATION FORM FOR IMATINIB/DASATINIB

Please send applications and prescriptions to: The CML Co-ordinator PHARMAC P O Box 10254 Wellington Phone: 04 460 4990 Facsimile: 04 916 7571 Email: mary.chesterfield@pharmac.govt.nz

Patient Details (Acceptable to attach hospital sticker) Title (circle): Surname: First Name/s: Address: Mr/Mrs/Miss/Ms/Dr NHI No:

Gender (circle): Phone No:

Male/Female

DOB:

Details of Applying Practitioner Name: NZMC reg no Address:

Details of patient’s General Practitioner Name: Address:

Phone No: Fax No: Speciality (tick): Haematology Oncology

Phone No:

Treatment Requested (tick Imatinib or Dasatinib) Imatinib Dose mg/day To be prescribed as monotherapy Please tick boxes as applicable:

OR

Dasatinib

Dose

mg/day

Chronic Phase (imatinib maximum dose 400mg daily) (dasatinib maximum dose 100mg daily) Accelerated Phase (imatinib maximum dose 600mg daily) (dasatinib maximum dose 140mg daily) Blast Crisis Phase (imatinib maximum dose 600mg daily) (dasatinib maximum dose 140mg daily) Initial Application CML Confirmed by Haematologist Renewal Application Renewal Number:

Compliance (prescriber determined) Please tick if applicable

Provide most recent results for the following where appropriate (It is acceptable to attach lab results) Cytogenetic results provided for 3 renewal (and other renewals if available) Absolute Neutrophil count Test Date: ________x10 /L

9 rd

Platelets Test Date: ______% ______% ______% ______% ______%

________x10 /L Bone marrow blasts promyelocytes Ph+ metaphases (or FISH Ph+ score) Q-PCR bcr-abl ______% ______% ______% ______% ______%

9

Peripheral blood blasts basophils promyelocytes FISH Ph+ score Q-PCR bcr-abl

Extramedullary disease Yes No See discontinuation guidelines in Pharmaceutical Schedule

I Confirm the above details are correct and that in signing this form I understand that I may be audited.

Signed: ______________________________________________

Date: _______________________

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GASTROINTESTINAL STROMAL TUMOUR (GIST) TREATMENT APPLICATION FORM FOR IMATINIB MESYLATE

Phone: 04 460 4990 Facsimile: 04 916 7571 Email: mary.chesterfield@pharmac.govt.nz

Please send applications and prescriptions to:

The GIST Co-ordinator PHARMAC PO Box 10-254 WELLINGTON

Patient Details (Acceptable to attach hospital sticker) Title (circle): Surname: First Name/s: Address: Mr/Mrs/Miss/Ms/Dr NHI No:

Gender (circle): Phone No:

Male/Female

DOB:

Details of Applying Practitioner Name: NZMC reg no. Address:

Details of patient’s General Practitioner Name: Address:

Phone No: Fax No:

Phone No:

INITIAL APPLICATION Prerequisites: Subsidised for use as monotherapy, maximum dose 400mg daily (tick box where appropriate): Diagnosis of unresectable and/or metastatic malignant gastrointestinal stromal tumour (GIST) Immunohistochemical documentation of c-kit (CD117) expression by the tumour

Dose to be prescribed as monotherapy: RENEWAL – Gastrointestinal stromal tumour (GIST) Prerequisites (tick box where appropriate) Initial Renewal _______mg/day _______mg/day

Compliance (prescriber determined) with imatinib and adequate clinical response (prescriber determined). Describe below. ................................................................................................. ........................................................................................ ………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………. I confirm the above details are correct and that in signing this form I understand that I may be audited. Signed:……………………………………………………………… Date:…………………………………………………………..

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DISPATCH INSTRUCTIONS FOR:

Patient details Title: Mr/Mrs/Miss/Ms/Dr

Please send to: The Imatinib Co-ordinator PHARMAC P O Box 10-254 WELLINGTON

Surname: ……………………………………………….. First names: …………………………………………... Address: ………………………………………………... ……………………………………………………………... ………………………………………………………………. D.O.B: ……………………………………………………. NHI No: ………………………………………………….. DELIVERY ADDRESS Please send the supply of Imatinib: To Address 1 below:

Phone: 04 460 4990 Facsimile: 04 916 7571 Email: mary.chesterfield@pharmac.govt.nz

Address 1

If undeliverable at Address 1, please deliver to the alternative address below: Patient General Practitioner Other Patient General Practitioner Other Name: …………………………………………………… ……………………………………………………………… Address: ……………………………………………….. …………………………………………………………….. …………………………………………………………….. …………………………………………………………….. Phone No: ……………………………………………..

Name: …………………………………………………… ……………………………………………………………… Address: ……………………………………………….. …………………………………………………………….. …………………………………………………………….. …………………………………………………………….. Phone No: ……………………………………………..