This is the text extract for SA0976 - Dasatinib for treatment of Chronic Myeloid Leukaemia (CML), 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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DISPATCH INSTRUCTIONS FOR: Patient details Title: Mr/Mrs/Miss/Ms/Dr Please send to: The Dasatinib Co-ordinator PHARMAC P O Box 10-254 WELLINGTON

Surname: ……………………………………………….. First names: …………………………………………... Address: ………………………………………………... ……………………………………………………………... ……………………………………………………………… D.O.B: …………………………………………………… NHI No: …………………………………………………

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

DELIVERY ADDRESS Please send the supply of Dasatinib: To Address 1 below: Address 1 If undeliverable at Address 1, please deliver to the alternative address below: Patient General Practitioner Other Name: …………………………………………………… ……………………………………………………………… Address: ……………………………………………….. …………………………………………………………….. …………………………………………………………….. …………………………………………………………….. Phone No: …………………………………………….. Patient General Practitioner Other Name: …………………………………………………… ……………………………………………………………… Address: ……………………………………………….. …………………………………………………………….. …………………………………………………………….. …………………………………………………………….. Phone No: ……………………………………………..