This is the text extract for 3. Adults Renewal PAH application form, browse documents here.

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Renewal Application / Request for Change of Therapy for Pulmonary Arterial Hypertension Treatments for Adults (and children aged over 10 years) Use this form for renewal applications and applications for therapy changes. Initial approval is valid for a period of six months. Subsequent approvals are valid for twelve months.

Please send applications to:

PAH Panel Coordinator PHARMAC P O Box 10-254 WELLINGTON Phone: 04 9167 512 Facsimile: 04 460 4858 Email : PAH@pharmac.govt.nz

Patient Details – patient sticker is acceptable Surname: First Name/s: NHI No: Gender: D.O.B: Address: q Male q Female

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

q q

Cardiac catheterisation report Echo results

Phone No: Email:

Home:

Work:

Mobile:

Patient’s Physician Name: NZMC Registration Number: Practice Address:

Phone No: Mobile No: Fax No: Email: Signature of applying physician: Date:

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Current treatment and dosing: Treatment requested q Endothelian receptor antagonists [bosentan] q Phosphodiesterase type-5 inhibitors [sildenafil] q Prostacyclin analogues [iloprost] Are you applying for a change in therapy? Are you applying for combination treatment? Are you applying for a renewal of current treatment only? q Yes q Yes q Yes q No q No q No

If applying for a change of therapy or combination therapy, please indicate reasons for change: Intolerance of current treatment (please provide details below) Lack of response to current treatment (please provide details below) Disease progression following previous disease stability (please provide details below) Please discuss the rationale for requesting a change in treatment: q q q

Note: · · · · Where the patient has not responded to sildenafil monotherapy, clinicians may apply for alternative monotherapy within 6 months of treatment initiation. Combination sildenafil/bosentan sildenafil/iloprost therapy may be approved after failure of monotherapy Combination bosentan/iloprost therapy will not be approved, except for patients with documented intolerance of sildenafil. Triple therapy (bosentan/sildenafil/iloprost) will not be approved.

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Status Update NYHA/WHO functional class 2 q 3 q 4 q

Test results Height (cm): Weight (kg): BMI (kg/m2):

Six minute walk test (x2 if annual renewal ie done every six months): Distance walked (m): SpO2: Heart Rate: Borg Index: Baseline: Baseline: Pre: Nadir: Maximum: Post:

Brain natriuretic peptide if available – please provide reference data:

Right heart cardiac catheter (please attach report) All patients: Repeat cardiac catheter reports must be provided one year after the start of treatment. § Stable patients: cardiac catheter reports are required at 2 to 4 year intervals depending upon patient progress. § Unstable patients: Where escalation of treatment is requested, a repeat right heart cardiac catheter is mandatory. Testing centre: Pulmonary capillary wedge pressure: (Threshold: ≤ 15 mmHg) Mean: Pulmonary artery pressures: Systolic: Diastolic: Mean right atrial pressure: Pulmonary vascular resistance: Cardiac output Cardiac index q Wood units q International units

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Cardiac catheter contraindicated: Discussion:

Echocardiography (please attach full report) Echo RVP Echo RAP

Current symptoms / general well-being over previous 6 or 12 months (as applicable)