This is the text extract for 5. Children Renewal PAH application form, browse documents here.

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Renewal 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

Echocardiography report Cardiac catheterisation 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 patient’s progress on treatment and evidence for response: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ __________________________________________________________________

In addition to anticipated duration, please describe proposed criteria for weaning therapy. Note - If ongoing therapy planned at 1 year of age (or following a year of therapy) it is recommended consideration should be given to risk/benefit of cardiac catheterisation if not performed prior. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

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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 q Tick q

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Test results Height (cm): Height centile: Oxygen Saturations Current oxygen use: Results of overnight oximetry: Hospital admissions since approval (please list dates and diagnoses) ICU days since approval: 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: Weight (kg): Weight centile: On Room air _____ On Oxygen at ___ Litres/min: ____

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Right heart cardiac catheter if performed (please attach reports) Testing centre: Date of current catheter: Pulmonary capillary wedge pressure: (Threshold: ≤ 15 mmHg) Pulmonary artery pressures: (mPAP >25mmHg at rest) Mean right atrial pressure: Pulmonary vascular resistance: Cardiac output Cardiac index Cardiac catheter contraindicated: Discussion: q Wood units Mean: Systolic: Diastolic: Date of previous catheter:

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