Microsoft word - 1) apr registration_final v8 (w therapy v9)_updated december 2013

ANTIRETROVIRAL PREGNANCY REGISTRY
ANTIVIRAL THERAPY DURING PREGNANCY
(Initiated at registration and completed at follow-up)
The Registry assigned, non-patient identifying patient ID number or
Patient (Log) ID:
Sponsor MCN
Complete as much of this page as applicable at Registration. A copy of this form will be sent to you in the expected month of
delivery for completion.
4. ANTIVIRAL THERAPY DURING PREGNANCY
1. Use the med. codes below for antiviral medication taken during pregnancy. If not coded, Specify Medication.
Abacavir (ZIAGEN®, ABC)
Zalcitabine (HIVID®, ddC)
Abacavir generic – Hetero
Zidovudine (RETROVIR®, ZDV)
Abacavir generic – Apotex
Zidovudine oral generic – Ranbaxy
Abacavir (unknown manufacturer)
Zidovudine oral generic – Teva/GSK
Didanosine (VIDEX®, VIDEX® EC, ddI)
Zidovudine oral generic – Roxane/BI
Didanosine generic – Teva Pharmaceuticals
Zidovudine oral generic – Aurobindo
Didanosine generic – Aurobindo
Zidovudine oral generic – Cipla
Didanosine generic – Mylan
Zidovudine oral generic – Mylan
Didanosine (unknown manufacturer)
Zidovudine oral generic – Hetero
Efavirenz (SUSTIVA®, EFV)
Zidovudine oral generic – HEC Pharm
Efavirenz (STOCRIN®, EFV)
13.99 Zidovudine oral (unknown manufacturer)
Efavirenz generic – Hetero
Amprenavir (AGENERASE®, APV)
Efavirenz (unknown manufacturer)
Indinavir (CRIXIVAN®, IDV)
Lamivudine (EPIVIR®, 3TC)
Delavirdine mesylate (RESCRIPTOR®, DLV)
Lamivudine generic – Hetero
Lopinavir+ritonavir (KALETRA®, ALUVIA®, LPV/r)
Lamivudine+tenofovir df generic – Hetero
Abacavir+lamivudine+zidovudine (TRIZIVIR®, TZV)
Lamivudine generic – Apotex
Tenofovir disoproxil fumarate (VIREAD®, TDF)
Lamivudine generic – Aurobindo
Tenofovir disoproxil fumarate generic – Hetero
Lamivudine (unknown manufacturer)
19.99 Tenofovir disoproxil fumarate (unknown manufacturer)
Lamivudine+zidovudine (COMBIVIR®, ZDV+3TC)
Adefovir dipivoxil (HEPSERA®, ADV)
Lamivudine+zidovudine generic – Hetero
Adefovir dipivoxil generic – Sigmapharm
Lamivudine+zidovudine generic – Teva Pharmaceuticals
20.99 Adefovir dipivoxil (unknown manufacturer)
Lamivudine+zidovudine generic – Aurobindo
Enfuvirtide (FUZEON®, T-20)
Lamivudine+zidovudine generic – Lupin
Atazanavir sulfate (REYATAZ®, ATV)
Lamivudine+zidovudine (unknown manufacturer)
Emtricitabine (EMTRIVA®, FTC)
Nelfinavir (VIRACEPT®, NFV)
Fosamprenavir calcium (LEXIVA®, FOS)
Nevirapine (VIRAMUNE®, VIRAMUNE® XR™, NVP)
Abacavir+lamivudine (EPZICOM®, EPZ)
Nevirapine generic – Hetero
Tenofovir disoproxil fumarate+emtricitabine (TRUVADA®, TVD)
Nevirapine generic – Prinston
Entecavir (BARACLUDE®, ETV)
Nevirapine generic – Sciegen
Tipranavir (APTIVUS®, TPV)
Nevirapine generic – Apotex
Efavirenz+tenofovir disoproxil fumarate+emtricitabine
Nevirapine generic – Aurobindo
(ATRIPLATM, ATR)
Nevirapine generic – Strides
Telbivudine (TYZEKA®, SEBIVO ®, LdT)
Nevirapine (unknown manufacturer)
Darunavir (PREZISTA®, DRV)
Ritonavir (NORVIR®, RTV)
Raltegravir (ISENTRESS® RAL)
Saquinavir (FORTOVASE®, SQV-SGC)
Maraviroc (SELZENTRY®, CELSENTRI®, MVC)
Saquinavir mesylate (INVIRASE®, SQV-HGC)
Etravirine (INTELENCE®, ETR)
Stavudine (ZERIT®, d4T)
Rilpivirine (EDURANT®, RPV)
Stavudine generic – Mylan
Rilpivirine+Emtricitabine+Tenovfovir Disoproxil Fumarate
Stavudine generic – Aurobindo
(COMPLERA®, CPA; EVIPLERA®, EPA)
Stavudine generic – Cipla
Elvitegravir+Cobicistat+Emtricitabine+Tenofovir Disoproxil
Stavudine generic – Hetero
Fumarate (STRIBILD™, STB)
Stavudine generic – unknown manufacturer
Dolutegravir (TIVICAY®)
2. In the following table, describe each course or change in route for each applicable therapy. Med. Code (1-38)
Total Daily Dose
Route
Pt Taking Med.
Date Treatment Course Began
Date Treatment Stopped
(mg/day or
(enter code)
at
(DD/MMM/YYYY)
(DD/MMM/YYYY)
if no code indicated, please
mg/kg/hr)
1 = oral
Conception?
OR
OR
write medication name and
2 = IV
1 = Yes
Gestational Age Course Began
Ongoing?
indicate if generic
3 = sub-Q
2 = No
(0 weeks = prior to conception)
3 = Unknown
Course
Phone: (US, Canada) 800-258-4263 (Toll Free) or 910-256-0238 (local) Phone: (International) +1-910-256-0238 Phone: (UK, Germany, France) 00800-5913-1359 (Toll Free) Phone: (Europe) +32-2-714-5028 Internet: www.APRegistry.com

Source: http://www.apregistry.com/forms/therapy_form.pdf