High Cost Drug Funding Request Form – Vancomycin



[pic]CALGARY ZONE

High Cost Drug Funding Request Form – vancomycin

NOTE: vancomycin is NOT effective, by the oral route, for the treatment of systemic infections

|Patient Information |Care Centre |

|Patient Code[1] |Date of Birth (YMD) | |

|      |     /    /   |      |

|Physician Information |

|Surname First |

|            |

|New Renewal NOTE: Funding may or may not be approved by Alberta Health Services, Calgary |

|Approved for use under the following conditions for Clostridium Difficile Associated Diarrhea (CDAD): | |

|Initial Disease Occurrence: | |

|Metronidazole treatment failure of mild/moderate cases | |

|For treatment at a dose of 125 mg po qid for 10 days (14 days if immunocompromised), when first-line treatment with metronidazole |Check Condition: |

|500 mg po tid or 250mg po qid for 10 days (14 days if immunocompromised) has failed | |

|Note: Patients on metronidazole should not be deemed treatment failures until at least 6 days of therapy have been given. The mean | |

|time to resolution of diarrhea is 2-4 days2 | |

|Initial Treatment of severe cases | |

|For treatment at a dose 125 mg po qid for 10 days (14 days if immunocompromised) if signs and symptoms indicate a severe case of CDAD| |

| | |

|Where severe disease is defined as WBC>15,000cells/uL, serum creatinine 1.5x above baseline or signs/symptoms of megacolon | |

| | |

|Relapse of CDAD | |

|1st recurrence | |

|For treatment of disease relapse at a dose of 125 mg po qid for 10 days (14 days if immunocompromised), when a second course of | |

|metronidazole 500 mg tid or 250mg po qid for | |

|10 days (14 days if immunocompromised) has failed. | |

|Note: Relapse is defined as recurrence of watery stools and positive stool toxin test within 6 weeks after previous successful | |

|treatment with either metronidazole or vancomycin. Successful treatment means the patient was asymptomatic at least 4 days after | |

|completing antibiotic treatment. | |

| | |

|2nd recurrence (or more) | |

|Tapered therapy should be utilized after a treatment course of vancomycin 125 mg po QID for 10 days (14 days if immunocompromised). | |

|Example of pulse therapy: | |

|125 mg po bid for 7 days | |

|125 mg po daily for 7 days | |

|125 mg po every other day for 7 days | |

|125 mg po every 3 days for 14 days | |

|Drug Dose:       |      | |

|Physician & Pharmacy Provider have ensured compliance with Use Conditions? |

|Yes No |

|Additional Information Relating to Request (i.e. previous drug trial information including doses and duration, frequency of follow-up with specialist, consult |

|report information, etc.): |

|      |

|Physician’s or Pharmacist’s Name: |Initial Drug Provision Date (Y/M/D) |Processing Instructions: Pharmacy Provider email to Supportive |

|      |     /    /   |Living and Long Term Care at: |

| | |cc.drugmanagement@albertahealthservices.ca OR Physician fax to: |

| | |(403) 943-0232 |

To type within each cell, use the TAB key

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[1]Patient Code: First four letters o⁦畳湲浡ⱥ映汯潬敷⁤祢映物瑳琠潷氠瑥整獲漠⁦楧敶慮敭㈍䌠污慧祲䠠慥瑬⁨敒楧湯䄠畣整䌠牡⁥湉敦瑣潩牐癥湥楴湯☠䌠湯牴汯倠潲牧浡映潯湴瑯獥‬敓瑰浥敢⁲〲㌰഍ഃЍ഍ഃЍ഍䍈⁄畆摮湩⁧敒畱獥⁴潆浲›䍈ⵄ㈲उ敲楶敳ㅤ⸲㤰㈮ഷ഍潄丠瑯吠楨牆浯䌠慨瑲഍₩〲㌱䄠扬牥慴䠠慥瑬⁨敓癲捩獥ꀮ吠楨⁳慭整楲污椠⁳牰癯摩摥漠湡∠獡椠≳‬眢敨敲椠≳戠獡獩‮䆠扬牥慴䠠慥瑬⁨敓癲捩獥搠敯⁳潮⁴慭敫愠祮爠灥敲敳瑮瑡潩牯眠牡慲瑮ⱹ攠灸敲獳‬浩汰敩⁤牯猠慴畴潴祲‬獡琠f surname, followed by first two letters of given name

2 Calgary Health Region Acute Care Infection Prevention & Control Program footnotes, September 2003

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Do Not Thin From Chart

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