This is the text extract for 4. Children Initial PAH application form, browse documents here.

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Initial Application for Funding of Pulmonary Arterial Hypertension Treatment Application for children less than 10 years for PDE-5 inhibitor (sildenafil) treatment This form is applicable for younger patients requiring PDE-5 inhibitor (sildenafil) monotherapy only. If other treatments are required use the form for adults and children aged over 10 years.

Please send applications to:

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

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

q q q

Cardiac catheterisation report Echocardiography report CT report

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

Phone No: Email:

Home:

Work:

Mobile:

Physician Details Name: NZMC Registration Number: Practice Address:

Phone No: Mobile No: Fax No: Email:

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Signature of applying physician: Treatment requested q Phosphodiesterase type-5 inhibitors [sildenafil]

Date:

Please discuss the rationale for the proposed treatment regime: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Please describe anticipated benefits of treatment _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

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Basis of request for PAH treatments Diagnosis Patient has been diagnosed as having pulmonary arterial hypertension WHO (Venice) clinical classification Group One – Pulmonary arterial hypertension Idiopathic PAH Familial PAH Associated with other diseases: Connective tissue disease Congenital systemic pulmonary shunts Portal hypertension HIV infection Drugs/toxins Other (specify) Associated with significant venous or capillary involvement Pulmonary veno-occlusive disease Pulmonary capillary haemangiomatosis Persistent pulmonary hypertension of the newborn Group Four – Pulmonary hypertension due to chronic thrombotic and/or embolic disease only Group Five – Other pulmonary hypertension (specify) q q q q q q q q q q q q Tick q

q

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Test results Height (cm): Height centile: Gestation at birth: Number of hospital admissions: ICU Days: History of ventilation: Current oxygen use: Saturations Results of overnight oximetry: Chest X Ray findings: Six minute walk test: (if relevant) Distance walked (m): SpO2 Heart Rate Borg Index Other: Brain natriuretic peptide if available – please provide reference data: Radiology CT Chest results – if applicable (attach report) Baseline: Baseline: Pre: Nadir: Maximum: Post: On Room air: _____ On Oxygen at ___ Litres/min: ____ Weight (kg): Weight centile: Birth weight (centile):

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Right heart cardiac catheterisation (if performed) Testing centre: Pulmonary capillary wedge pressure: Pulmonary artery pressures: Mean: Systolic: Mean right atrial pressure: Pulmonary vascular resistance – Wood units: Cardiac output: Cardiac index: Cardiac catheter contraindicated: Discussion: q Pulmonary vascular resistance Indexed Threshold: ≤ 15 mmHg Threshold > 25 mmHg at rest Diastolic:

Echocardiography (please attach report) Estimate of PA pressure How obtained? (TR jet vs PDA or other) Systemic BP RV dilation RV function Structural congenital heart disease (please describe)