This is the text extract for SA0855 – Multiple Sclerosis treatments, Renewal Application form for beta-interferon or glatiramer acetate, browse documents here.

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MSTAC RENEWAL APPLICATION FOR FUNDING OF BETA-INTERFERON OR GLATIRAMER ACETATE

For patients who are currently being treated with beta-interferon or glatiramer acetate (with New Zealand government funding)

Please send applications to:

The Co-ordinator MSTAC PHARMAC P O Box 10-254 WELLINGTON

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

Applications must be complete and accompanied by all supporting data. Have you attached:

q q q q

MR scan reports? Other laboratory reports? Relapse history form? EDSS summary?

Patient Details Title: Surname: First Name/s: Address: Mr/Mrs/Miss/Ms/Dr

Gender: D.O.B: NHI No: Phone No: Fax No: Email Address: Cell phone No:

Male/Female

Applying Practitioner Speciality (circle): Surname: First Name: NZMC Registration Number: Address:

Neurologist or Physician

Phone No: Fax No: Email Address: Cell phone No: Patient’s General Practitioner Surname: First Name: Address:

Phone No: Fax No:

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Application for Renewal of Subsidy for Disease Modifying Treatment for MS

Patient Details Surname: First Name/s: NHI No: Baseline EDSS : Relapse Rate : Treatment Start Date: Number of relapses in the past 12 months of treatment:

(Please also complete details on separate form)

Treatment Since Last Review: q q q q

Betaferon Avonex Copaxone IV Immunoglobulin

Notes on Changes in Treatment:

Adherence to Treatment q q q

Excellent Satisfactory Poor

Comments

Responsiveness to BIF Treatment Neutralising Anti-bodies Yes/No MxA mRNA Response Yes/No

Results:

Results:

General Comments:

Neurologist’s Declaration I confirm that the above and attached details are correct and that in signing this form I understand that I may be audited. I recommend that beta-interferon or glatiramer acetate for this patient be continued. Signature: ______________________________ Date: __________________________________

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EDSS

Patient Details Surname: First Name/s: NHI No: DATE EDSS ASSESSED: ASSESSOR:

Functional System Pyramidal Cerebellar Brainstem Sensory Bowel and Bladder Visual (or Optic Nerve) Cerebral (or Mental) Other Measured Walking Distance without aid or rest. If Aids used to walk - type of aid used and distance walked without rest, using the aid. EDSS SCORE

Score

Please Describe Main Signs

VAR =

VAL =

3

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EXPANDED DISABILITY STATUS SCALE (EDSS)

0

1.0 1.5 2.0 2.5 3.0 3.5 4.0

-

Normal neurologic exam (all grade 0 in Functional Systems [FS]; Cerebral grade 1 acceptable). No disability, minimal signs. (one or two FS grade 1 excluding Cerebral grade 1). No disability, minimal signs in three or more FS (three or more FS grade 1 excluding Cerebral grade 1). Mild disability in one FS (one FS grade 2, others 0 or 1). Mild disability in two FS (two FS grade 2, others 0 or 1). Moderate disability in one FS (one FS grade 3, others 0 or 1) or mild disability in three or four FS (three/four FS grade 2, others 0 or 1) though fully ambulatory. Fully ambulatory but with moderate disability exceeding 3.0 (one FS and one or two or more grade 2; or two FS grade 3; or five FS grade 2 (with other FS 0 or 1). Fully ambulatory without aid or rest for 500 metres or more. One FS grade 4 (others 0 or 1) or combinations of lesser grades exceeding limits of previous steps. Able to walk without aid or rest some 500 metres. Fully ambulatory without aid or rest for about 300 metres. One FS grade 4 (others 0 or 1) or combinations of lesser grades exceeding limits of previous steps. Ambulatory without aid or rest for about 200 metres (Usual FS equivalents are one grade 5 alone, others 0 or 1; or combinations of lesser grades exceeding specifications for step 4.5). Ambulatory without aid or rest for about 100 metres. (Usual FS equivalents are one grade 5 alone, others 0 or 1; or combinations of lesser grades exceeding those for step 5.0). Intermittent or unilateral constant assistance (cane, crutch or brace) required to walk about 100 metres with or without resting. (Usual FS equivalents are combinations with more than two FS grade 3+). Constant bilateral assistance (canes, crutches, or braces) required to walk about 20 metres without resting. (Usual FS equivalents are combinations with more than two FS grade 3+). Unable to walk beyond about 5 metres even with aid, essentially restricted to wheelchair, wheels self in standard wheelchair and transfers alone. (Usual FS equivalents are combinations with more than one FS grade 4+, very rarely pyramidal grade 5 alone). Unable to take more than a few steps, restricted to wheelchair, may need aid in transfer, wheels self but cannot carry on in standard wheelchair a full day, may require motorised wheelchair. (Usual FS equivalents are combinations more than one FS grade 4+). Essentially restricted to bed or chair or perambulated in wheelchair but retains many self-care functions and generally has effective use of arms. (Usual FS equivalents are combinations with grade 4+ in more than one FS). Essentially restricted to bed much of the day, has some effective use of arm(s), retains some self-care functions. (Usual FS equivalents are combinations, generally 4+ in several systems). Helpless bed patient, can communicate and eat. (Usual FS equivalents are combinations, mostly grade 4+). Totally helpless bed patient, unable to communicate effectively or eat/swallow. (Usual FS equivalents are combinations, almost all grade 4+). Death due to MS.

4.5 5.0 5.5 6.0 6.5 7.0

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7.5

-

8.0

-

8.5 9.0 9.5 10

-

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Relapse Summary (Renewal Application)

Patient Details Surname: First Name/s: NHI No: Date Assessed: Please record details for all relapses in the past year (since last approval). Onset of relapse (month & year) Duration of relapse (weeks) New or recurrent symptom(s) of relapse. (Sufficient to change EDSS or a FS by 1 point) Period of any hospitalisation during relapse (days) Treatment Relapse Monitored/confirmed by:

o o

Steroids Other

o o

Steroids Other

o o

Steroids Other

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