Quantity Level Limit Program: Limit per Refill Quantity Quantity Acanya 1.2 - 2.5% Emend® 40 and 125 mg Acular LS® ophthalmic Emend® 80 mg Acuvail® Emend® Unit of Use Pack Aczone® 5% Epiduo™ Adrenaclick® 0.15 and 0.3 mg EpiPen® 0.15 and 0.3 mg Afinitor® 2.5 and 5 mg Evoclin® Afinitor® 10 mg Extina® Foam Aldara cream Famvir® 12
Butler.rcboe.orgPlease take this letter and information form to your doctor if you choose to go to a private doctor for testing and treatment. Information must be faxed back to the health department by your doctor. TB Exposure Follow-up by Private Doctor
This patient has chosen to be evaluated by you due to exposure to an Isoniazid-
resistant case of active TB. The health department is officially responsible for
documentation of surveillance and management of TB and its contacts. We can also
provide treatment and services to the patient free of charge. Below are guidelines
related to the patient’s exposure history.
Testing by the Mantoux method is required and self-reading is not allowed per CDC
recommendations. Because this patient is a contact to a person with active TB, a
reading of 5 mm or greater is considered positive.
Since the index case is Isoniazid-resistant, the State recommends the following for latent TB infection: Rifampin 10 mg/kg (maximum dose 600 mg) for patients who are 16 years old and older for a period of 6 months and Rifampin 10-20 mg/kg (maximum dose 600 mg) for patients who are 15 years old and younger for a period of 6 months. The State also recommends baseline HIV test, hepatitis B and hepatitis C profiles if indicated, CBC with platelets, and liver function panel. These baseline lab measurements are not mandatory for children less than 16 years of age, unless a complicating medical condition (e.g., HIV, liver disease, renal disease, cardiac disease) or lifestyle is known or suspected. If indicated, a pregnancy test is to be done. Over-all evaluation of patient is recommended at least every month, which includes any symptoms of hepatotoxicity (those considered at risk of hepatotoxicity should have monthly LFTs), Any other symptoms, TB symptoms, and adherence to the regimen. It is strongly recommended that the patient take the entire daily dose at one time to prevent inadequate treatment due to possible forgetfulness. The State recommends discontinuation of Rifampin if AST/ALT levels are equal to or greater than 3 times the upper limit of normal in the presence of symptoms of adverse events. Discontinue Rifampin if AST/ALT levels are equal to or greater than 5 times the upper limit of normal in an asymptomatic patient. If the patient reports any symptoms of adverse reactions, obtain liver function tests immediately and HOLD Rifampin pending MD evaluation of results. If you have any questions or concerns regarding the patient and the State guidelines, please call us at 706-721-5840. We are requesting that you fax the information form to 706-721-5845. TB Exposure Private Doctor Follow-up Information must be sent to the health
Please fax information to attention of Richmond County TB Nurse at
For any questions, please contact Richmond County TB Nurse at 706-721-5840.
City ____________________ State _________________ Mantoux Test: read skin test 48 to 72 hours later. Induration, not redness, is to If vesicles only are present, the area they cover are to be read in millimeters and documented as a positive with vesicles only. If first test is negative, repeat second skin test 8-10 weeks later. Test #2 Date placed CXR required for positive skin test, TB symptoms both with and without positive skin test, patients with diseases/conditions that suppress the immune system, such as diabetes, cancer, leukemia, kidney disease, gastrectomy, jejunoileal by-pass, Abnormal __________________________________________________________ If yes, weight__________ If patient is a TB suspect or case, the Law requires that the local health department be notified at 706-721-5840. Medications for case and TB suspect status are weight-based as well. Medication names/doses/frequency 1. 2. 3.
Frank R. Lichtenberg – “Quality of life”/functional status• Biomedical innovation is responsible for a significant part of improvements in health 1950- 1955- 1960- 1965- 1970- 1975- 1980- 1985- 1990- 1995- More developed regions Less developed regions 1950- 1955- 1960- 1965- 1970- 1975- 1980- 1985- 1990- 1995- Nursing home residents 65 years and over per 1,000 population,