Formularios y Documentos
Aquí puede descargar el formulario que necesita para inscribirse en XOLAIR 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.
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
para inscribirse en XOLAIR 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
XOLAIR® (omalizumab) for subcutaneous use is an injectable prescription medicine used to treat:
- moderate to severe persistent asthma in patients 6 years of age or older whose asthma symptoms are not controlled by asthma medicines called inhaled corticosteroids. A skin or blood test is performed to see if a patient has allergies to year-round allergens.
- chronic idiopathic urticaria (CIU; chronic hives without a known cause) in patients 12 years of age and older who continue to have hives that are not controlled by H1 antihistamine treatment
XOLAIR is not used to treat other allergic conditions, other forms of urticaria, acute bronchospasm or status asthmaticus.
Important Safety Information
The most important information patients should know about XOLAIR is that a severe allergic reaction called anaphylaxis can happen when a patient receives XOLAIR. The reaction can occur after the first dose, or after many doses. It may also occur right after a XOLAIR injection or days later. Anaphylaxis is a life-threatening condition and can lead to death. Patients must go to the nearest emergency room right away if they have any of these symptoms of an allergic reaction:
- wheezing, shortness of breath, cough, chest tightness, or trouble breathing
- low blood pressure, dizziness, fainting, rapid or weak heartbeat, anxiety, or feeling of “impending doom”
- flushing, itching, hives, or feeling warm
- swelling of the throat or tongue, throat tightness, hoarse voice, or trouble swallowing
The patient’s healthcare provider will monitor the patient closely for symptoms of an allergic reaction while they are receiving XOLAIR and for a period of time after the patient’s injection. The patient’s healthcare provider should talk to the patient about getting medical treatment if they have symptoms of an allergic reaction after leaving the healthcare provider’s office or treatment center.
Patients must not receive XOLAIR if they are allergic to omalizumab or any of the ingredients in XOLAIR.
Before receiving XOLAIR, patients must tell their healthcare provider about all of their medical conditions, including if they:
- have any other allergies (such as food allergy or seasonal allergies)
- have sudden breathing problems (bronchospasm)
- have ever had a severe allergic reaction called anaphylaxis
- have or have had a parasitic infection
- have or have had cancer
- are pregnant or plan to become pregnant. It is not known if XOLAIR may harm a patient’s unborn baby
- are breastfeeding or plan to breastfeed. It is not known if XOLAIR passes into breast milk. Talk with your healthcare provider about the best way to feed your baby while you receive XOLAIR
Patients must tell their healthcare provider about all the medicines they take, including prescription and over-the-counter medicines, vitamins, or herbal supplements.
- XOLAIR should be given by a healthcare provider, in a healthcare setting
- XOLAIR is given in 1 or more injections under the skin (subcutaneous), 1 time every 2 or 4 weeks
- In asthma patients, a blood test for a substance called IgE must be performed prior to starting XOLAIR to determine the appropriate dose and dosing frequency
- In patients with chronic hives, a blood test is not necessary to determine the dose or dosing frequency
- Patients must not decrease or stop taking any of their other asthma or hive medicine unless their healthcare providers tell them to
- Patients may not see improvement in their symptoms right away after XOLAIR treatment
Possible side effects of XOLAIR
XOLAIR may cause serious side effects, including:
- See,“What is the most important information I should know about XOLAIR” in the XOLAIR Medication Guide at http://www.xolair.com regarding the risk of anaphylaxis
- Cancer. Cases of cancer were observed in some people who received XOLAIR
- Inflammation of your blood vessels. Rarely, this can happen in people with asthma who receive XOLAIR. This usually, but not always, happens in people who also take a steroid medicine by mouth that is being stopped or the dose is being lowered. It is not known whether this is caused by XOLAIR. Tell your healthcare provider right away if you have rash; chest pain; shortness of breath; or a feeling of pins and needles or numbness of your arms or legs
- Fever, muscle aches, and rash. Some people who take XOLAIR get these symptoms 1 to 5 days after receiving a XOLAIR injection. If a patient has any of these symptoms, they must tell their healthcare provider
- Parasitic infection. Some people who are at a high risk for parasite (worm) infections, get a parasite infection after receiving XOLAIR. The patient’s healthcare provider can test the patient’s stool to check if they have a parasite infection
- Heart and circulation problems. Some people who receive XOLAIR have had chest pain, heart attack, blood clots in the lungs or legs, or temporary symptoms of weakness on one side of the body, slurred speech, or altered vision. It is not known whether this is caused by XOLAIR
The most common side effects of XOLAIR:
- In adults and children 12 years of age and older with asthma: pain especially in the arms and legs, dizziness, feeling tired, skin rash, bone fractures, and pain or discomfort of the ears
- In children 6 to less than 12 years of age with asthma: common cold symptoms, headache, fever, sore throat, pain or discomfort of your ear, abdominal pain, nausea, vomiting and nose bleeds
- In people with chronic idiopathic urticaria: nausea, headaches, swelling of the inside of the nose, throat or sinuses, cough, joint pain, and upper respiratory tract infection
These are not all the possible side effects of XOLAIR. Patients should call their doctor for medical advice about side effects.
Report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch.Report side effects to Genentech at (888) 835-2555 or Novartis Pharmaceuticals Corporation at 888-669-6682.