Government of Ontario: Ministry of Health

Recombinant Human Erythropoietin
Funding Enrollment for E.S.R.D. Patients

Known risk factors for non-response to rHuEPO include (to be excluded prior to treatment):

a) Infection/Inflammation/Malignant Processes

b) Aluminum Toxication

c) Occult blood loss/Surgery (w/o blood loss)

d) Iron Deficiency (folic acid or vitamin B12)

e) Severe osteitis fibrosa cystica

f) Hemolysis

g) Underlying hematologic diseases (i.e., thalassemia, refractory anemia, or other myelodysplastic disorders)

Dosage and administration

Please refer to the H.P.B. approved Product Monograph (attached to Working Group Report).

Initial dosage (u/week)


Physician

Care should be taken to avoid wastage of this product.

The use of erythropoietin for all patients treated with the product is to be summarized quarterly (based on the Enrollment form data).

The collection of the information on this form is authorized by Clause 22(b) of O. Reg. 518/88 under the Public Hospitals Act R.S.O. 1980, Chapter 410, for the purpose of assessing monitoring patient use of erythropoietin and payment therefor. For information about collection practices contact: the Director, Drug Programs Policy and Strategy Branch, 3rd floor, 5700 Yonge Street, North York ON M2M 4K5. Telephone 416-327-8109.

White – Ministry of Health, Drug Programs Policy and Strategy Branch
Canary – Dialysis Centre
Pink – Hospital Pharmacy and Therapeutics Committee