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London Cancer New Drugs Group
Application form for the London Cancer Drugs Fund
THIS APPLICATION MUST BE COMPLETED AND APPROVED BY THE RELEVANT CANCER
NETWORK TEAM BEFORE THE PATIENT IS STARTED ON TREATMENT
FORM to access Interim Cancer Drug Fund
Name of Drug(s), APPLICATION
Dose(s) and
Ruxolitinib
5 forms
to 25mg
orally twice daily*
Only
fully completed
will be accepted.
schedule:
This route of funding
applies for the
list of table
drugs identified
*see suggested
dosing
below by the
London Cancer New Drugs for Funding when used in accordance with the previously agreed and
Indication:
Myelofibrosis
IPSSbelow
Intermediate
Risk-1
above
listed criteria. All eligibility
criteria listed
MUST apply
to the or
patient.
Drug(s)/Regimen used in
Single agent
combination:
Regimen Name (OPCS v 4.6)
NA
Line of treatment
2nd line
Y/N
Estimated Cost of CDF drug treatment (per 28 day Cycle) BNF costs plus
VAT at 20%
5mg bd
15mg bd
20mg bd
25mg bd
NB, If patient specific costs are required for local purposes, please enter here:
(Rounded to the nearest vial size, plus VAT at 20%)Enter N/A if section does NOT Apply
£2016
£4032
£4032
£6048
Will this drug be provided to the patient via a homecare provider
Y/N
Please indicate whether the patient meets the following LCNDG CDF criteria
Please insert
Yes/No
Primary Diagnosis: Secondary myelofibrosis in myeloproliferative disease or
Chronic idiopathic myelofibrosis ICD10 Code 47.4
Patient has either constitutional symptoms which have not responded to standard
systemic therapy or has developed side effects to systemic therapy
Patient has splenomegaly or hepatomegaly which has not responded to standard
systemic therapy or has developed side effects to systemic therapy (including splenic
irradiation)
Treatment with ruxolitinib will be stopped in the following circumstances:
 Haematological toxicity, not resolving on dose reduction
 Progressive durable spleen or liver enlargement by > 5cm beyond baseline,
with lack of symptom response
 Worsening of disease related symptoms from baseline, without meaningful
sleen or liver response
Patient has ECOG Performance status < 3
Patients renal and hepatic function will be monitored and dose reduced to once daily if
GFR<30ml/min or in the presence of any degree of liver impairment.
Patient is not receiving eltrombopag or romiplostim or any of the prohibited medicines
listed below. Please note medical management for restricted medicines
Patient’s treatment with Ruxolitinib will be initiated after the Marketing Authorization in
the UK was granted (i.e. after 24th August 2012)
This patient’s treatment will be managed under the supervision of a haemato-oncologist,
competent in the use of systemic anti-cancer therapy
Number of cycles intended (or until
progression)
Frequency of
cycles
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Initially every
2 to 4 weeks,
then 4 weekly
Proposed Treatment start date
Patient Details
Patient NHS No.
Registered GP name
Patient Hospital No.
GP post code
Patient initials
Patient Date of Birth
CDF_Ruxolitinib_2nd_line_MF_Version 1.0
Y/N
Y/N
Y/N
Y/N
Page 1 of 4
Patient’s PCT
The consultant agrees to provide outcome data in relation to this patient’s treatment, on completion of
therapy.
Failure to submit an end of treatment summary will result in suspension of payment to the Trust.
Trust
Contact details of Trust
Oncology Pharmacist
Consultant
Consultant Contact
details (email/phone)
(Block Capitals)
Consultant signature
1. Enter electronic signature OR
Date of completion
2. Print name & submit e-mail from
Consultant, or with e-mail
confirmation of consultant
initiation of treatment OR
3. Print form, consultant to sign and
Fax (SELCN Only)
Submit completed application form to the Cancer Network Management team
If the form is e-mailed, an electronic copy of the Consultant’s signature is acceptable.
Contact details: [email protected]
Application approved on behalf of Cancer Network Management Team
Approved by Name and Designation
Signature, Date of approval & copy sent to London CDF audit office
Platelets
(x 109/L)
Ruxolitinib Dose
50-100
5mg twice daily
100-200
15mg twice daily
>200
20mg twice daily to a Maximum 25mg twice daily
Comments
Consider a lower starting
dose in patients with
symptomatic anaemia
NB see restricted/prohibited medicines below
CDF_Ruxolitinib_2nd_line_MF_Version 1.0
Page 2 of 4
Restricted Medicines
Prohibited
Medicines
-Potent
CYP 3A4 Inducers
Rifampicin
St John’s Wort
CYP 3A4 Inhibitors
*Strong inhibitor –
Dose reduction of Ruxolitinib required
a
Moderate inhibitor,
b
Weak inhibitor,
c
all other inhibitors
For weak to moderate inhibitors consider
alternative therapies where possible, dose
adjustment not required
Clarithromycin*
Itraconazole*
Ketoconazole*
Nefazodone*
Telithromycin*
Aprepitanta
Erythromycina
Fluconazolea
Grapefruit juicea
Verapamila
Diltiazema
Cimetidineb
Amiodaronec
Chloramphenicolc
Delaviridinec
Diethyl-dithiocarbamatec
Fluvoxaminec
Gestodenec
Imatinibc
Mibefradilc
Mifepristonec
Norfloxacinc
Norfluoxetinec
Starfruitc
Voriconazolec
Cancer
Network
Application forms available at
South
East London
North
Central London
Weak to moderate CYP
3A4 inducers
For weak to moderate
inducers consider
alternative therapies
where possible, dose
adjustment not
required
Barbiturates
Carbamazepine
Glucocorticoids
Modafinil
Nevirapine
oxycarbazepine
Phenobarbital
Phenytoin
Pioglitazone
Rifabutin
Applications to,
e-mail
Applications
to, Fax
Telephone
contact
http://www.selcn.nhs.uk/content/dynamic.asp?id=869&dyna
mic_id=88&sn=Cancer%20Drugs%20Fund%20documents
[email protected]
0207 188 7120
Jacky Turner
0207 188 7090
http://www.nlcn.nhs.uk/interim-cancer-drugs-fund
nclcdfrequests
@nhs.net
Applications not
accepted by Fax
Dermot Ball
0207 685 6212
btl-tr.icdfnelcn
[email protected]
Applications not
accepted by Fax
Raj Nijjar
0207 377 7241
North
East London
http://www.nelcn.nhs.uk/content/projects.asp?
projectid=128
North
West London
http://www.nwlcn.nhs.uk/Healthcare%20Professionals/Refer
ence%20Library/interim-cancer-drug-fund-2010.htm
wms-pct.cancerdrug
[email protected]
Applications not
accepted by Fax
Pauline McCalla
0203 350 4552
South
West London
Available via individual Trust intranet sites
smpt.ICDFrequests
[email protected]
Applications not
accepted by Fax
Susan Kilby 0208
407 3929
CDF_Ruxolitinib_2nd_line_MF_Version 1.0
Page 3 of 4
PCT
Cancer Network
Bexley
Bromley
Greenwich
Lambeth
Lewisham
Southwark
Barnet
Enfield
Haringey
Camden
Islington
(West Essex)
Barking & Dagenham
City & Hackney
Havering
Newham
Redbridge
Tower Hamlets
Waltham Forest
Brent
Ealing
Hammersmith & Fulham
Harrow
Hillingdon
Hounslow
Kensington & Chelsea
Westminster
Croydon
Kingston
Richmond and Twickenham
Sutton and Merton
South
East London
North
Central London and West Essex
North
East London
North
West London
South
West London
Wandsworth
CDF_Ruxolitinib_2nd_line_MF_Version 1.0
Trust
Guy's & St Thomas'
King's College Hospital
Lewisham Healthcare Trust
South London Healthcare @ PRUH
South London Healthcare @ QEW
South London Healthcare @ QMS
Barnet & Chase Farm
North Middlesex
Princess Alexandra Harlow (PAH)
Royal Free
UCLH
Whittington
BHR
Barts and The London
Homerton
Newham
Whipps Cross
Chelsea & Westminster
Ealing
Hillingdon
Imperial
Northwick Park
West Middlesex
Epsom & St Helier
Croydon
Kingston
St Georges
RMH
Page 4 of 4