The form must be completed electronically and emailed to the Lead Pharmacist Neurosciences Incomplete forms



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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

Consultant

NN

NHS Number

4681001481

GP post code

KT18 5NZ

Surname

  Kamalabaskaran   




PCT code

(if available)



     

First name

Chinniah

DOB

14-May-1932

Height

     

Gender

M

Weight

     

Category:

NHS

Private

Private to NHS

Category 2 / Other

Transferred from other trust

No

Yes

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




Blue

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

Blue




Inflammatory myopathies (Dermatomyositis, Polymyositis, IBM)

Long-termDiagnosis 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)




Blue

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

Red

Blue

Rasmussen syndrome

Long-term – When other therapies (such as steroids) have failed




Blue

Stiff person syndrome

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




Blue
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