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  • Pemesanan Actemra 1

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    Farmasi Rstciremai
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    The document is an informed consent form for the use of Actemra (tocilizumab) to treat two hospitalized COVID-19 patients at Hospital Tk. III 03.06.01 CIREMAI. It certifies that Actemra is intended for the unlicensed treatment of COVID-19, which is not an approved indication in Indonesia. The hospital acknowledges this unapproved use and the treating physician signs the form. Additional context provided notes that Actemra is only approved in Indonesia for rheumatoid arthritis and juvenile arthritis, not COVID-19. Adverse events from its use for COVID-19 should be reported to the drug company.

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    The document is an informed consent form for the use of Actemra (tocilizumab) to treat two hospitalized COVID-19 patients at Hospital Tk. III 03.06.01 CIREMAI. It certifies that Actemra is intended for the unlicensed treatment of COVID-19, which is not an approved indication in Indonesia. The hospital acknowledges this unapproved use and the treating physician signs the form. Additional context provided notes that Actemra is only approved in Indonesia for rheumatoid arthritis and juvenile arthritis, not COVID-19. Adverse events from its use for COVID-19 should be reported to the drug company.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    22 views2 pages

    Pemesanan Actemra 1

    Uploaded by

    Farmasi Rstciremai
    The document is an informed consent form for the use of Actemra (tocilizumab) to treat two hospitalized COVID-19 patients at Hospital Tk. III 03.06.01 CIREMAI. It certifies that Actemra is intended for the unlicensed treatment of COVID-19, which is not an approved indication in Indonesia. The hospital acknowledges this unapproved use and the treating physician signs the form. Additional context provided notes that Actemra is only approved in Indonesia for rheumatoid arthritis and juvenile arthritis, not COVID-19. Adverse events from its use for COVID-19 should be reported to the drug company.

    Copyright:

    © All Rights Reserved
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    of 2

    INFORMED CONSENT for ACTEMRA UN

    UN-LICENSED
    LICENSED INDICATION

    Hospital Tk.III 03.06.01 CIREMAI hereby certifythat:

    order to PT Tempoforproduct ACTEMRA, 2 vials (as per Purchase Order


    number 1 as per-attached)
    attached) is intended for the treatment of
    hospitalized COVID-19 patients.

    Patient Initial(s): Mr. Eko Harjono

    dr. Dicki Harnanda Prihandono, Sp.P,M.Kes


    Treating Physician(s):dr.

    Tk. III 03.06.01 CIREMAI is fully aware that the usage of drugs as mentioned
    HospitalTk.
    above is for an unlicensed indication inIndonesia
    inIndonesia.

    Hospital Authorized
    rized Person,

    dr. Dicki Harnanda Prihandono, Sp.P, M.Kes


    Pulmonologist
    March 18, 2021

    [ In Indonesia, Actemra (tocilizumab) is approve by BPOM for Rheumatoid Arthritis


    (RA), Polyarticular Juvenile Idiopathic Arthritis (pJIA), and Systemic Juvenile Idiopathic
    Arthritis (sJIA). It is not approved for the treatment of hospitalized COVID
    COVID-19 patients.
    benefit profile of Actemra use is important for Patient Safety Risk
    As evaluating the risk-benefit
    Management, Roche encourage HCP to report the use of Actemra in COVID COVID-19
    https://cprt.roche.com/or contact
    patients and its adverse event through online form: https://cprt.roche.com/
    Roche Patient Safety at indonesia.safety@roche.com].
    indonesia.safety@roche.com
    INFORMED CONSENT for ACTEMRA UN
    UN-LICENSED
    LICENSED INDICATION

    Hospital Tk.III 03.06.01 CIREMAI hereby certifythat:

    order to PT Tempoforproduct ACTEMRA, 2 vials (as per Purchase Order


    number 2 attached) is intended for the treatment of
    as per-attached)
    hospitalized COVID-19 patients.

    Patient Initial(s): Mrs. Apriliana

    dr. Dicki Harnanda Prihandono, Sp.P,M.Kes


    Treating Physician(s):dr.

    Tk. III 03.06.01 CIREMAI is fully aware that the usage of drugs as mentioned
    HospitalTk.
    above is for an unlicensed indication inIndonesia
    inIndonesia.

    Hospital Authorized
    rized Person,

    dr. Dicki Harnanda Prihandono, Sp.P, M.Kes


    Pulmonologist
    March 18, 2021

    [ In Indonesia, Actemra (tocilizumab) is approve by BPOM for Rheumatoid Arthritis


    (RA), Polyarticular Juvenile Idiopathic Arthritis (pJIA), and Systemic Juvenile Idiopathic
    Arthritis (sJIA). It is not approved for the treatment of hospitalized COVID
    COVID-19 patients.
    benefit profile of Actemra use is important for Patient Safety Risk
    As evaluating the risk-benefit
    Management, Roche encourage HCP to report the use of Actemra in COVID COVID-19
    https://cprt.roche.com/or contact
    patients and its adverse event through online form: https://cprt.roche.com/
    Roche Patient Safety at indonesia.safety@roche.com].
    indonesia.safety@roche.com

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