IWK

1.902.470.8888

1.888.470.5888

Emergency: 911
Telecare: 811
Poison: 1-800-565-8161
5850/5980 University Ave., Halifax, NS B3K 6R8

Requests for Palivizumab : Palivizumab (Synagis®)

The referring physician completes the Nova Scotia RSV Prophylaxis Request Form 2017-2018. This form requires that the referring physician indicate that the parent/guardian was informed and consented to their child’s demographic information being shared with AbbVie Corporation in Montreal (AbbVie) for the purpose of ordering “product” (ie. palivizumab prophylaxis ), and that the health condition that puts the child at high risk for complicated RSV be indicated (check box). AbbVie shares the demographic information with the Nova Scotia Department of Health and Wellness for the purposes of monitoring costs/utilization of palivizumab. The Provincial Palivizumab Working Group conducts this review yearly prior to establishing provincial prophylaxis guidelines. Nova Scotia also contributes to the national body of evidence/knowledge/practice regarding RSV prophylaxis by sharing aggregate data. Although direct identifiers are not shared, the Nova Scotia Personal Health Information Act requires consent for release of any personal health information, including demographics.

In all cases, to order palivizumab, the requesting physician should fax a fully completed Nova Scotia RSV Prophylaxis request form to AbbVie. The request form now includes an area to indicate if this is the first time product is requested (ie “initial” dose) or if it is a request for additional product (ie “subsequent” dose). For subsequent requests, the patient reference number assigned by AbbVie upon “initial” request must be provided. This will insure each infant/child has a unique reference number and only one file. As palivizumab is sold on a “non-returnable” and “non-refundable” basis, pharmacies or offices having inventory from last season should still submit a request form to AbbVie but reduce doses requested so remaining inventory may be used first to eliminate expiry of product. Those requests that are for “other” children considered to be at high risk for contracting RSV should be faxed to AbbVie along with the two appropriate letters providing medical justification for ordering the product.

Palivizumab funding will be limited to 5 doses per season as outlined in Table 1. The initial dose should be given between December 1st and January 6th and every 4 weeks to a maximum of 5 doses. This seasonal approach is based on when infants are deemed to be most at risk for contracting the disease in Nova Scotia (January to May). Nova Scotia epidemiology experts will continue to monitor this defined season. Table 1 outlines the number of doses required dependent on the date of request for palivizumab.

Table 1: Guidance for number of doses depending on request date - (Dose is 15 mg/kg as per package insert)

Request Date Number of Doses
December Five Doses
January Four Doses
February Three Doses
March Two Doses
April One Dose

It is recommended that palivizumab be delivered to hospital pharmacy services due to strict storage requirements, and be administered to patients through same-day, centralized clinics wherever possible. Infants in the Halifax (formerly the Halifax Regional Municipality) may receive palivizumab through the IWK RSV Prevention Clinic. Infants in Colchester County and the Municipality of East Hants may receive palivizumab through the Colchester East Hants Health Center (contact the Maternal/Child Unit at (902) 893-5544). Infants in the region of Cape Breton may receive palivizumab through a clinic at the Cape Breton Regional Hospital by contacting (902) 567-7844. Requests for indications that meet the provincial guidelines and do not require medical consultation will be immediately dispensed by AbbVie.

Requests that require medical consultation ("cardiac indications" and "other children considered at high risk for contracting RSV") will be faxed to the IWK Health Centre Utilization Monitoring Program (IWKUMP) by AbbVie. The IWKUMP will refer these requests for consultation to the appropriate clinical specialists at the IWK Health Centre and once approved will request dispensing of palivizumab by AbbVie.