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RWE retrospective study of safety and efficacy of Romiplostim in ITP

Patient ID *

Date of Birth *

Gender*

Male Female

Date of ITP Diagnosis *

Baseline Platelet Count (x 10^9/L) *

Previous ITP Treatments*

Corticosteroids Immunoglobulins Rituximab Splenectomy Other

Romiplostim Treatment Details

Date of Romiplostim Initiation *

Romiplostim Dosage and Frequency *

Initial dose (µg/kg) *

Frequency (e.g., weekly)*

Duration of Romiplostim Treatment*

Start Date *

End Date (if applicable)

Reason for Discontinuation (if applicable)

Adverse Event Lack of Efficacy Patient Preference Other

Platelet Counts During Treatment (Whatever is available):

Achievement of Platelet Count ≥50 x 10^9/L *

Yes No

Duration of Sustained Platelet Response (≥50 x 10^9/L for ≥4 consecutive weeks) *

Start Date *

End Date *

Bleeding Events

Date of Event	Severity
	Mild Moderate Severe

Adverse Events (AEs)	Date of Onset	Description of AE	Severity	Relationship to Romiplostim
			Mild Moderate Severe	Not Related Possibly Related Probably Related Definitely Related

Concomitant ITP Medications During Romiplostim Treatment	Medication Name	Dosage	Frequency	Start Date	End Date

HRQoL Assessments (if available)	Date of Assessment	Fatigue Score (0-10 scale)	Physical Functioning Score (0-10 scale)	Emotional Well-being Score (0-10 scale)

Requirement of Rescue Therapies *

Yes No

Date of Study Completion for Patient *

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