Assessment and documentation in the patient record by a pharmacist is required prior to initial drug provision (new admission or new starts). Form submission is required within six weeks following admission or upon completion of the pregabalin trial. Processing Instructions: Please complete the form in its entirety. Pharmacy provider email to ISFL Long Term Care Pharmacist at: pharmacist/physician fax to OR 403-943-0232 Funding Eligibility New Start Date started (yyyy-Mon-dd) New Admission Resident Code Year of Birth Date of Admission (yyyy) (yyyy-Mon-dd) Prescribing Information Dosing Information (reason for prescribing, specialist or clinic involvement) Protocol 1: New Start / Step Therapy Formulary first-line: Gabapentin Criteria met / For treatment of neuropathic pain associated with diabetic neuropathy, acknowledged neuralgia, spinal cord injury or pain associated with fibromyalgia. The resident must have failed an adequate trial of therapy with the Formulary first-line agent gabapentin: Outcome of gabapentin trial date and outcome): ; and (specify A failed gabapentin trial occurs when dosage titration to achieve pain control is not possible due to renal function and/or unacceptable or non-resolving side effects which are impairing function, such as somnolence or cognitive impairment. An adequate trial is defined as a separate treatment course of gabapentin (which may involve more than gabapentin) used for a period of 4 to 6 weeks. Must complete a pregabalin trial. A pregabalin trial of 4 to 6 weeks is used to determine objective and subjective improvement in symptoms from baseline and compared to gabapentin. Outcomes of pregabalin trial (specify date and outcome): ; and The Interdisciplinary team has reviewed and incorporated pain management strategies into the resident’s care plan; and Pregabalin will be assessed with regular medication reviews for determination of ongoing benefit.
Assessment and documentation in the patient record by a pharmacist is required prior to initial drug provision (new admission or new starts). Form submission is required within six weeks following admission or upon completion of the pregabalin trial. Processing Instructions: Please complete the form in its entirety. Pharmacy provider email to ISFL Long Term Care Pharmacist at: OR pharmacist/physician fax to 403-943-0232 Funding Eligibility New Start New Admission Date started (yyyy-Mon-dd) Resident Code Year of Birth (yyyy) Date of Admission (yyyy-Mon-dd) Prescribing Information (reason for prescribing, specialist or clinic involvement) Dosing Information Protocol 1: New Start / Step Therapy Formulary first-line: Gabapentin For treatment of neuropathic pain associated with diabetic neuropathy, neuralgia, spinal cord injury or pain associated with fibromyalgia. Criteria met / acknowledged The resident must have failed an adequate trial of therapy with the Formulary first-line agent gabapentin: Outcome of gabapentin trial (specify date and outcome): ; and A failed gabapentin trial occurs when dosage titration to achieve pain control is not possible due to renal function and/or unacceptable or non-resolving side effects which are impairing function, such as somnolence or cognitive impairment. An adequate trial is defined as a separate treatment course of gabapentin (which may involve more than gabapentin) used for a period of 4 to 6 weeks. Must complete a pregabalin trial. A pregabalin trial of 4 to 6 weeks is used to determine objective and subjective improvement in symptoms from baseline and compared to gabapentin. Outcomes of pregabalin trial (specify date and outcome): ; and The Interdisciplinary team has reviewed and incorporated pain management strategies into the resident’s care plan; and Pregabalin will be assessed with regular medication reviews for determination of ongoing benefit.