ESA APPRISE Oncology Program Patient and Healthcare Professional (HCP) Acknowledgment Form (Acknowledgment Form) For the use of erythropoiesis stimulating agents (ESAs*) ( alfa), ( alfa), or ( alfa).
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How to use or fill out the Acknowledgment Form (Acknowledgment Form) - ESA APPRISE online
Filling out the Acknowledgment Form for the ESA APPRISE program is an important step in ensuring proper management of erythropoiesis stimulating agents. This guide will walk you through each section of the form online, providing clear and supportive instructions for users of all experience levels.
Follow the steps to complete the Acknowledgment Form online.
- Press the ‘Get Form’ button to access the Acknowledgment Form and open it in the designated editor.
- Begin by reviewing the Medication Guide thoroughly with the patient. Ensure they understand the contents, as this is a critical component of the acknowledgement process.
- In the next section, counsel the patient regarding the risks and benefits associated with ® or ®/®. It's vital for them to have a clear understanding before the initiation of ESA therapy.
- Complete each required section of the form alongside the patient. This may involve obtaining their printed name, signature, and date, as well as any necessary information about their healthcare representative.
- Collect the prescriber’s information in the Healthcare Professional Acknowledgment section, ensuring they provide their signature and the Prescriber Enrollment ID#.
- After all fields are filled out correctly, double-check for accuracy. Once you confirm that everything is complete, proceed to save changes, download, or print the form if necessary.
- Lastly, ensure the completed form is faxed to the ESA APPRISE Oncology Program Call Center or mailed using the provided prepaid envelope. Maintain a copy separately from the patient’s medical records.
Complete your Acknowledgment Form online today for efficient document management.
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What is the most common cause of ESA hyporesponsiveness?
Iron deficiency, the most common cause of ESA hyporesponsiveness, can be absolute or functional.
Which is a possible risk with the use of ESAs when targeting hemoglobin levels ≥ 11g dL?
Using ESAs to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular events and has not been shown to provide additional patient benefit.
What is the risk of ESAs?
These risks include: ESAs may cause tumors to grow faster. ESAs may cause some patients to die sooner. ESAs may cause some patients to develop blood clots, and serious heart problems such as a heart attack, heart failure or stroke.
What is the FDA black box warning for erythropoietin?
The warning states: Avoid serious cardiovascular and arterial and venous thromboembolic events by using the lowest dose of , , or that will gradually raise the hemoglobin concentration to the lowest level sufficient to avoid the need for blood transfusion.
What is an example of ESAs?
Erythropoietin stimulating agents (ESAs) are recombinant versions of EPO produced pharmacologically. Examples of ESAs are , , and methoxy polyethylene glycol- beta.
What are ESA medications?
ESAs are used to treat anemia caused by chronic kidney failure, some anticancer drugs, and certain treatments for HIV. They may also be used to lower the number of blood transfusions needed during and after certain major surgeries. Examples of ESAs are alfa (, ) and alfa ().
What is the black box warning for ESAs?
WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE.
What is the apprise REMS program?
ESA APPRISE was a risk evaluation and mitigation strategy (REMS) program created to ensure that the benefits outweighed the risks when ESAs are used to minimize red blood cell transfusions in patients with cancer and chemotherapy-induced anemia.
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