Avsola (Infliximab-axxq)

• Avsola Benefit Investigation Form
• Avsola Patient Enrollment Form

1. Physician Orders: Los Angeles
2. Physician Orders: Santa Monica
3. Physician Orders: Sherman Oaks

Avsola (infliximab-axxq) [Amgen]

• Rheumatoid Arthritis
  • 3mg/kg IV at 0, 2 and 6 weeks, then q 8 weeks. Dose may be increased up to 10mg/kg or given as often as every 4 weeks.
• Crohn’s Disease
  • 5mg/kg IV at 0, 2 and 6 weeks, then q 8 weeks. Dose may be increased up to 10mg/kg q 8 weeks.
    **“^‡For adult patients who respond and then lose their response, consider increasing maintenance dose to 10 mg/kg. Patients who do not respond by week 14 are unlikely to respond with continued dosing and consideration should be given to discontinue AVSOLA™ in these patients.”
• Ankylosing Spondylitis
  • 5mg/kg IV at 0, 2 and 6 weeks, then q 6 weeks.
• Ulcerative Colitis, Psoriatic Arthritis, Plaque Psoriasis
  • 5mg/kg IV at 0, 2 and 6 weeks, then q 8 weeks.
• Need patient weight, Hep B S Ag, PPD or QuantiFERON

Instructions

1. Please open authorization forms at left. Fill out the forms on your computer, save and print.
2. Open Physician Orders for the office of your choice (at left). Save to your computer, print and fill out.
3. The following tests should be performed and test results faxed to Pacific Infusion before the patient’s first visit:
   Infliximab – CXR, PPD
4. Fax the following to Pacific Infusion Center (310) 297-9222:
   • Completed and signed forms/order
   • Copy of the patient’s insurance card(s)
   • Demographics
   • OV notes
   • Tried and failed medications
   • Labs
   • Drug Enrollment Forms
5. After the patient’s infusion appointment, one of our nurses will fax a copy of the infusion notes to your office.