New Drug Application

(for inclusion in the CCCH Drug Formulary)

Date_______________________
Rquesting physician:_________________________________________________________
Infomation regarding new drug:
Classification
Generic Name
Trade Name(s)
Distributor
Manufactor(s)
Dosage Form(s)

Antibiotic
Cefuroxime Axetil
Pediacef
Oxford Distributions Incorporated
Lloyd Laboratories
Adult Uncomplicated UTI 125mg bid
Resp tract infections 250-500 mg bid.
Children<2yrs Otitis media 250mg or
15mg/kg bid up to a max of 500mg
daily,>3mth 125mg or 10mg/body wt
bid up to a max of 250mg daily.

Pharmacological action or use of this drug (Attach Certificate of Product Reg.)

Advantages over those listed in the formulary
Same efficacy
Effectiveness
Efficiency
Affordable
Which drugs that this new one would replace?

*Attach other references (eg bioequivalence study,bioassay,pricelist)

(This portion is for the Therapeutic Committee)
Approved
Denied
Chairman of Therapeutics Committee:____________________________
Members:_______________________________
______________________________
______________________________
______________________________

ug Formulary)

te_______________________

_________________

of Product Reg.)