Formularios y Documentos

Aquí puede descargar el formulario que necesita para inscribirse en Esbriet Access Solutions y otra información importante. Recuerde que su médico también debe rellenar un formulario para inscribirle.

Iniciar la Inscripción con el Formulario PAN

Para empezar, rellene el formulario llamado PAN. Puede encontrar el formulario a continuación.

SMN

Su médico también tiene que rellenar un formulario llamado SMN. Cuando tengamos estos dos formularios, podremos empezar a trabajar con usted y la consulta de su médico. Usted no tiene que rellenar ningún dato en este formulario.

Guía de Discusión Sobre el Coste del Tratamiento

Este paquete de información incluye:

  • Cuestiones que debería plantearse preguntar al personal de su consultorio médico después de que se le haya recetado un medicamento de Genentech
  • Información para inscribirse en Esbriet Access Solutions
  • Una copia del formulario PAN

PAN=siglas en inglés de Autorización del Paciente y Aviso de Solicitud Para Transmitir Información Médica a Genentech Access Solutions y a Genentech® Access to Care Foundation.

SMN=siglas en inglés de Declaración de Necesidad Médica.

Important Safety Information & Indication

What it Treats

About Esbriet

Esbriet is a prescription medicine used to treat people with a lung disease called idiopathic pulmonary fibrosis (IPF).

It is not known if Esbriet is safe and effective in children.

Select Important Safety Information

Before you take Esbriet, tell your doctor if you:

  • have other medical conditions (particularly liver or kidney problems).
  • are a smoker.
  • are or plan to become pregnant or breastfeed (Esbriet has not been studied in these patients).
  • are taking any prescription or over-the-counter medicines, vitamins, or herbal supplements.

What are the possible side effects of Esbriet?

Esbriet may cause serious side effects, including:

  • liver problems. Call your doctor if you have symptoms such as yellowing of your skin or eyes, dark or brown urine, pain on the upper right side of your stomach area, bleeding or bruising more easily than normal, or increased fatigue. Your doctor will also do regular blood tests to check your liver.
  • sun sensitivity and rash. When you are outside, use sunscreen (SPF 50) and wear a hat and clothes that cover your skin to avoid getting a sunburn.
  • stomach problems. Esbriet may cause stomach problems such as nausea, vomiting, diarrhea, indigestion, heartburn, and stomach pain.

Your doctor may change your dose or discontinue Esbriet if side effects do not go away.

The most common side effects of Esbriet include upper respiratory tract infections, feeling tired, headache, dizziness, loss of appetite, sinusitis, insomnia, or weight loss.

These are not all the possible side effects of Esbriet.

What should you avoid while taking Esbriet?

  • Direct exposure to sunlight, or light from sunlamps and tanning beds.
  • Other medicines that can make your skin sensitive to sunlight.
  • Smoking, which may affect how well Esbriet works.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch or to Genentech at 1-888-835-2555.

Please see full Prescribing Information, including Patient Information, for additional important safety information.