This is the text extract for SA1162 – Sunitinib, browse documents here.

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Ministry of Health Phone 0800 243 666 APPLICANT (stamp or sticker acceptable)

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA1162

April 2012

PATIENT NHI: ...................................................... REFERRER Reg No: ............................................

Reg No: ................................................................ First Names: ......................................................... First Names: ......................................................... Name: ................................................................... Surname: .............................................................. Surname: .............................................................. Address: ............................................................... DOB: ..................................................................... Address: ............................................................... ............................................................................... Address: ............................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... Fax Number: ......................................................... ............................................................................... Fax Number: .........................................................

Sunitinib

INITIAL APPLICATION Applications only from a relevant specialist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 3 months. Prerequisites (tick boxes where appropriate)

and

and and

and The patient has intermediate or poor prognosis defined as:

u u u u u

or

The patient has metastatic renal cell carcinoma

The patient is sunitinib treatment naive The patient received sunitinib prior to 1 November 2010 and disease has not progressed

The patient has good performance status (WHO/ECOG grade 0-2) The disease is of predominant clear cell histology

and

u u u u u u u

or or or or or

Lactate dehydrogenase level > 1.5 times upper limit of normal Haemoglobin level < lower limit of normal Corrected serum calcium level > 10 mg/dL (2.5 mmol/L) Interval of < 1 year from original diagnosis to the start of systemic therapy Karnofsky performance score of ≤ 70 ≥ 2 sites of organ metastasis

Sunitinib to be used for a maximum of 2 cycles

RENEWAL Current approval Number (if known):............................................................... Applications only from a relevant specialist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 3 months. Prerequisites (tick boxes where appropriate)

and

u u

No evidence of disease progression The treatment remains appropriate and the patient is benefiting from treatment

Note: Sunitinib treatment should be stopped if disease progresses. Poor prognosis patients are defined as having at least 3 of criteria 5.1-5.6. Intermediate prognosis patients are defined as having 1 or 2 of I confirm the above details are correct and that in signing this form I understand I may be audited. Signed: .............................................................................. Date: ...............................................

Post application to Ministry of Health, Private Bag 3015, Wanganui – Fax: 0800 100 131

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Ministry of Health Phone 0800 243 666 APPLICANT (stamp or sticker acceptable)

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 2

Form SA1162

April 2012

PATIENT NHI: ...................................................... REFERRER Reg No: ............................................

Reg No: ................................................................ First Names: ......................................................... First Names: ......................................................... Name: ................................................................... Surname: .............................................................. Surname: .............................................................. Address: ............................................................... DOB: ..................................................................... Address: ............................................................... ............................................................................... Address: ............................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... Fax Number: ......................................................... ............................................................................... Fax Number: .........................................................

criteria 5.1-5.6

I confirm the above details are correct and that in signing this form I understand I may be audited. Signed: .............................................................................. Date: ...............................................

Post application to Ministry of Health, Private Bag 3015, Wanganui – Fax: 0800 100 131