Amantadine Extended-Release (Gocovri®)
SELF ADMINISTRATION - Oral
Indication for Prior Authorization:
- Indicated for the treatment of dyskinesia in patients with Parkinson's disease receiving levodopa-based therapy, with or without concomitant dopaminergic medications
Patients must meet the following criteria for the indication(s) above:
- Used for the treatment of dyskinesia in patients with Parkinson's disease, confirmed by chart note documentation, AND
- Patient is receiving levodopa-based therapy, with or without concomitant dopaminergic medications, AND
- Patient has tried and failed amantadine immediate-release
- Gocovri® is contraindicated in patients with end stage renal disease.
Dosing:
- Initial: 137 mg once daily at bedtime
- After 1 week, increase to 274 mg (two 137 mg capsules) once daily at bedtime.
- Gocovri® is not interchangeable with other amantadine immediate- or extended-release products.
- Dose adjusted for renal impairment (contraindicated in patients with end stage renal disease)
Last review date: July 16, 2019