The form must be completed electronically and emailed to the Lead

The form must be completed electronically and emailed to the Lead Pharmacist Neurosciences Incomplete forms cannot be processed

Immunoglobulin Panel Request Form - Neurology

Hospital Number(patient label) H528577 NHS Number 4681001481 Kamalabaskaran Surname

Consultant GP post code

First name DOB

Chinniah 14-May-1932

(if available)

Gender

M

Category:

NHS

Transferred from other trust

NN KT18 5NZ

PCT code Height Weight

Private

Private to NHS

No

Yes

Category 2 / Other

Transfer Date

Transferred From Planned treatment date

As soon as available

Any indication NOT listed below requires INDIVIDUAL FUNDING from NHS ENGLAND Consultant to contact Specialist Pharmacist for guidance SGH indications for Use (Red and pre-approved blue indications only)

Short term

Long term

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) Short -term – Life threatening rapidly progressive neurological functional disability Long-term - Probable or definite diagnosis by a neurologist according to EFNS/IPNS GL AND Significant functional impairment inhibiting normal daily activities

Red

Blue

Guillain-Barré Syndrome (GBS) – or variant (including Bickerstaff’s) Short-term – Diagnosis of GBS or variant in hospital AND Significant disability (Hughes Grade 4) OR Disease progression

Red

Multifocal Motor Neuropathy (MMN) Long-term – Diagnosis by a neurologist of MMN with or without persistent conduction block AND Significant functional impairment inhibiting normal daily activities Myasthenia Gravis (MG) incl Lambert-Eaton Myasthenic Syndrome (LEMS) Short-term - Diagnosis by a neurologist OR Acute exacerbation (myasthenic crisis) OR Other immunosuppressive treatments are ineffective/inappropriate OR Weakness requires hospital admission OR Prior to surgery and/or thymectomy Inflammatory myopathies (Dermatomyositis, Polymyositis, IBM) Long-term – Diagnosis by a neurologist, rheumatologist, or immunologist of Patients with PM/DM with significant muscle weakness OR Dysphagia and have not responded to steroids and other immunosuppressive agents OR Patients with IBM who have dysphagia affecting nutrition (NOT with rapidly progressive IBM) Paraprotein associated demyelinating neuropathy (IgM, IgG or IgA) Short-term – Life-threatening rapidly progressive neurological functional disability Long-term - Diagnosis by a neurologist AND Significant functional impairment inhibiting normal daily activities AND Other therapies have failed, are contraindicated or undesirable Rasmussen syndrome Long-term – When other therapies (such as steroids) have failed

Appendix 7 - Immunoglobulin Panel Request Form NEUROLOGY

Blue

Blue

Blue

Red

Blue

Blue

Annett Blochberger [Lead Pharmacist Neurosciences] Approved by: IAP Jan 2012

Stiff person syndrome Long-term – Demonstration of auto-antibodies to GAD-65 or GAD-67

Blue

All Neurology Indications (red - blue – grey - black) CIDP [blue]

Diagnosis

#Click for list of GREY indications (NHS + Panel)

Other indications (not listed / NHS ENGLAND + Panel)

#Click for list of BLACK indications (not funded)

Intended Dose

Route

2g/kg

Short term

Long-term

(Max 3 courses in 3 months)

(proposed frequency – max 1 year)

IV

SC

Clinical details [DH selection criteria must be adhered to] CIDP. Complicated by chronic nocardia infection so can't have Steroids. Diagnosis and review criteria

CIDP

- MRC score - INCAT score - ONLS - Up and go 10 m walk (in secs) - Other validated measure

GBS

Disability grade at diagnosis

DM PM IBM

Improvement in functional scores (ADLs) OR quantitative muscle scores OR MRC muscle assessment OR Up-and-go 10m walk in secs

MG LEMS

Fatigability and weakness - Forward arm abduction time (up to 5 min) - Quantitative MG score (Duke) - Respiratory function (FVC) - Variation of myasthenic muscular score

MMN

- Power-score from 10-pre-defined pairs of muscles including 6 most affected muscles neuro-physiologically - ONLS - Up and go 10 m walk (in secs) - Other validated measure

Paraprotein IgM/IgG IgA

- MRC score - INCAT score - ONLS - Up and go 10 m walk (in secs) - Other validated measure

Rasmussen

Seizure frequency Cognitive state

Stiff Person

Stiffness Up-and-go-10m walk (in secs) Number of spasms a day

Measure

Score at baseline

Record 3 out of 5

MRC sum score ONLS

Record 3 out of 5

Appendix 7 - Immunoglobulin Panel Request Form NEUROLOGY

Annett Blochberger [Lead Pharmacist Neurosciences] Approved by: IAP Jan 2012

Complete for ALL indications (Immunoglobulin will not be dispensed if incomplete) Confidence in diagnosis Definite Highly likely (Please indicate)

Possible Yes

Known allergic reactions / contraindications to specific product If yes – state which product and type of reaction

Was plasma exchange considered? N/A Tried & failed

Not available

Alternatives tried before Ig

Current Treatment

None

Cyclophosphamide

Methotrexate

Ciclosporin

Corticosteroids

None

Rituximab

Methotrexate

Other (please state)

Requesting Clinician Prescriber name and designation

No

Not suitable

Cyclophosphamide Ciclosporin

Corticosteroids Rituximab

Other (please state)

Signature

Date

Approving consultant name

Panel Decision (For panel use only) Panel decision Automatic approval (indicate) Colour indication Red (indicate) Patient approved for use Short term If rejected state reason

Pre-approved

Approved on discussion

Not approved

Pre-agreed blue

Selected blue / grey

Black

Long term Review date

Additional comments Panel member

Signature

Date

Signature

Date

Database completion Database number: Data entered by:

Appendix 7 - Immunoglobulin Panel Request Form NEUROLOGY

Annett Blochberger [Lead Pharmacist Neurosciences] Approved by: IAP Jan 2012