Formularios y Documentos
Descargue el formulario que necesita para inscribirse en Genentech
Access Solutions y una guía útil para utilizarla en las consultas con
Iniciar la Inscripción con el Formulario de Consentimiento del Paciente
Para empezar, rellene el Formulario de Consentimiento del Paciente. Este formulario reemplaza la Autorización del Paciente y el Aviso de Solicitud Para Transmitir Información Médica a Genentech Access Solutions y a Genentech® Access to Care Foundation (PAN).
Puede cumplimentar este formulario de 1 de estas 3 formas:
- Rellene y envíe el formulario en línea
- Firmando un formulario impreso, tomando una fotografía de este y enviándola por mensaje de texto al número (650) 877-1111
- Firmando un formulario impreso y enviarlo por fax o por correo postal (o bien llevándolo a la consulta de su médico para que lo envíen desde allí)
Su médico también tiene que rellenar un formulario llamado Formulario de Servicio del Prescriptor. Una vez que hayamos recibido estos dos formularios, podremos empezar a colaborar con usted y con la consulta de su médico. Usted no tiene que rellenar nada en el Formulario de Servicio del Prescriptor.
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
para inscribirse en Tarceva Access Solutions
- Una copia del Formulario de Consentimiento del Paciente
Important Safety Information & Indication
What it Treats
Who is Tarceva (erlotinib) for?
- Tarceva is prescribed for patients with non-small cell lung cancer (NSCLC) whose cancer has spread to other parts of the body and that has certain types of epidermal growth factor receptor (EGFR) mutations. Your healthcare provider will perform a test to make sure that Tarceva is right for you.
- It is not known if Tarceva is safe and effective in EGFR mutations other than those included in the FDA-approved prescribing information.
- Tarceva is not meant to be used at the same time as certain types of chemotherapy for NSCLC.
Tarceva is approved for advanced-stage pancreatic cancer.
- Tarceva in combination with gemcitabine is prescribed for patients with advanced-stage pancreatic cancer whose cancer has spread, grown, or cannot be surgically removed and who have not received previous chemotherapy.
Important Safety Information
Contact your HCP right away if you experience any of the side effects listed below.
What are the possible side effects of Tarceva?
Tarceva can cause serious side effects, including:
- Lung problems (called interstitial lung disease [ILD] events). Tarceva has been shown to cause lung problems, including death. Symptoms of lung problems may include shortness of breath, cough, and fever. Tarceva may need to be stopped if you have any of these symptoms.
- Liver and kidney problems. Tarceva has been shown to cause severe kidney and liver problems, including death. Some people had their kidneys and liver stop working. Let your HCP know if you have a history of liver or kidney disease.
- Stomach and intestinal problems (called gastrointestinal [GI] perforation). Tarceva has been shown to cause GI perforation, which has led to death. A GI perforation is a hole that develops in your stomach or intestine. Tarceva patients may be at a higher risk for GI perforation if they:
- Are taking medicines including those that may help block the growth of blood vessels; steroids; non-steroidal anti-inflammatory drugs (NSAIDs); and certain chemotherapies. Always tell your HCP about any medicines you are taking.
- Have a history of ulcers or other stomach disease.
- Serious skin conditions. Tarceva has been shown to cause blistering and skin peeling. This may result in other serious skin disorders or death.
- Blood, bleeding, and clotting problems. Tarceva has been shown to cause certain blood problems and other bleeding and clotting problems. These have led to stroke and death.
- Eye disorders. Tarceva has been shown to cause dry eyes, unusual eyelash growth, or swelling of the cornea. The cornea is the clear coating of the eyeball. This swelling may irritate or damage the eye.
- Bleeding events when taking warfarin with Tarceva. Tell your HCP if you are taking a blood thinner, such as warfarin. Taking Tarceva with this medicine can cause death.
- Pregnancy. Tarceva can harm an unborn baby. Women should use effective birth control during treatment and for at least 1 month after the last dose of Tarceva. Tell your HCP if you have become pregnant, or if you think you may be pregnant, during treatment with Tarceva. Do not breast-feed during treatment with Tarceva and for 2 weeks after the final dose.
When should I call my HCP while taking Tarceva?
Call your HCP if you have:
- Serious or ongoing diarrhea, nausea (feeling sick to your stomach), loss of appetite, or vomiting.
- New or worsening shortness of breath or cough.
- Eye irritation.
- New or worsening rash, blistering, or peeling of the skin.
- Any changes in smoking habits.
What are some of the most common side effects of Tarceva?
- In 1st-line NSCLC treatment: Diarrhea, weakness, rash, cough, shortness of breath, loss of appetite (not wanting to eat).
- In maintenance/2nd- or 3rd-line NSCLC treatment: Rash and diarrhea.
- In pancreatic cancer treatment: Fatigue (feeling very tired), rash, nausea, loss of appetite, diarrhea.
What should I know about skin (including rash), hair, and nail problems or diarrhea while taking Tarceva?
- Skin (including rash):
- While taking Tarceva, rash could happen or get worse if the skin is exposed to the sun. You may want to use alcohol-free lotions and sunscreens or avoid being out in the sun.
- Your skin and nails may get darker. You may also have dry skin that may or may not crack. This most often happens with rash.
- Talk with your HCP if you notice a rash. He or she may be able to help you manage it.
- Hair and nails: Hair and nail problems have been seen in patients taking Tarceva. These include increased hairiness and brittle or loose nails.
- Diarrhea: Diarrhea can usually be treated with anti-diarrhea medicine. Your HCP can help you find the right medicine for you.
What should I do if I am taking or am prescribed other medicines or supplements while taking Tarceva?
- Always tell your HCP about all of the medicines and herbal supplements you are taking.
- DO NOT start taking any new medicines or herbal supplements before talking with your HCP.
- DO NOT eat grapefruit or drink grapefruit juice before talking with your HCP.
Will smoking affect my treatment with Tarceva?
- If you smoke, you should stop smoking before you start treatment with Tarceva.
- If you continue to smoke, your treatment with Tarceva may need to be adjusted. Talk with your HCP if you continue to smoke.
Always talk with your HCP about any side effects you may have with Tarceva.
You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.
Please see Tarceva full Product Information for additional Important Safety Information.