FORM FRM4905/1.1
Effective: 10/02/15
Therapeutic Apheresis Services
Request for Extracorporeal Photopheresis (ECP) - GvHD
-
-
-
Patient Demographics
Surname
First Name(s)
NHS Number
D.O.B
Hospital Number
Patient Address
Patient Contact Number
Hospital
Ward / out Patient
Consultant Name
Consultant Contact Number
Height
Weight
GP Name
GP Address (inc. postcode)
Is this an individual funding request? (acute GvHD only)
Yes
No
If yes, has funding been approved?
Yes
No
Is this an urgent referral?
Yes
No
Diagnosis
Chronic GvHD
Acute GvHD
Date of transplant
Date of onset GvHD
GvHD Inclusion Criteria (UK consensus statement 2008)
National funding agreement may not include patients who do not meet these criteria
1. Extensive chronic GVHD
2. Affecting skin and / or mucous membranes and / or liver
3. Requiring second / third line salvage therapy:
 Steroid refractory (minimal or no response to prednisolone 1mg/kg or equivalent after minimum 4
weeks treatment)
or
 Steroid dependant (inability to reduce to <10mg prednisolone or equivalent without GVHD flare)
or
 Unable to tolerate steroids
4. Tissue biopsy confirmation of diagnosis
Organ Involvement
Skin
Liver
Eye
Biopsy proven?
Mouth
Gut
Joint
Lung
Other (please specify)
Yes
No
Histology if available:
Current Treatment for GvHD
Prednisolone
Dose
Tacrolimus
Dose
Ciclosporin
Dose
Micophenylate
Dose
Other (please specify)
Dose
ECP Exclusion Criteria
(Template Version 01/11/13)
Cross-Referenced in Primary Document: MPD583
Page 1 of 2
FORM FRM4905/1.1
Effective: 10/02/15
Therapeutic Apheresis Services
Request for Extracorporeal Photopheresis (ECP) - GvHD
-
-
-
1. Pregnancy
Yes
No
2. History of heparin induced thrombocytopenia
Yes
No
3. Uncontrolled infection
Yes
No
4. Photosensitivity
Yes
No
5. Sensitivity to psoralen compounds
Yes
No
6. Aphakia
Yes
No
Yes
No
Yes
No
Yes
No
7. Neutrophil count < 1 x 109 / 1
8. Platelet count < 20 x
109
/1
9. Severe diarrhoea > 1000ml daily
Other Information
Additional details Including previous treatment:
Does the patient have any allergies?
Yes
No
(If yes, please specify)
Does the patient have any significant co-morbidities which would require modification of the procedure (e.g.
cardiovascular, renal, bleeding diathesis)?
Vascular Access
(ECP requires 16g access in antecubital fossa and second access in opposite limb of at least 20g)
Are peripheral veins adequate for apheresis?
Yes
No
Is an apheresis central line already in place?
Yes
No
Will an apheresis central line be inserted?
Yes
No
(If yes, please advise date of insertion)
Detail of member of staff completing this form
Name:
Grade:
Phone Number:
Date:
Email address:
Signature:
(*To ensure confidentiality please ensure an nhs.net email address is provided)
For use by NHS Blood & Transplant ONLY
Has the referral been accepted?
Yes
No
Comments:
(Template Version 01/11/13)
Cross-Referenced in Primary Document: MPD583
Page 2 of 2