XIAFLEX (collagenase clostridium histolyticum)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

  • Dupuytren's contracture (hand) in Adults
  • Peyronie's Disease

Patients must meet the following criteria for the indications above:

  • Patient must have a palpable cord

Dupuytren's Contracture

  • Diagnosis of Dupuytren's Contracture AND
  • Have at least one finger (not thumb) flexion contracture with a palpable cord of 20 to 100 degrees in the metatarsophalangeal joint (MP) or a proximal interphalageal (PIP) joint

Peyronie's Disease

  • Diagnosis of Peyronie's disease diagnosed by a urologist (prescriber need not be urologist)

The drug is not approved for any use not mentioned above:

  • Any condition not listed above as an approved condition

Dosing:

  • Xiaflex must be administered by a healthcare provider experienced in injection procedures of the hand

Dupuytren's Contracture

  • The dose of Xiaflex is 0.58 mg per injection into a palpable cord with a contracture of a metacarpophalangeal (MP) joint or a proximal interphalangeal (PIP) joint
  • Approximately 24 hours after injection, perform a finger extension procedure to facilitate cord disruption
  • Four weeks after the initial injection and finger extension, if a MP or PIP contracture remains, the cord may be re-injected with a single dose of 0.58 mg. Repeat finger extension in 24 hours
  • Injections and finger extension procedures may be administered up to 3 times per cord at approximately 4-week intervals

Peyronie’s Disease

  • Up to 2 injections of 0.58 mg injected into target plaque, administered 1 to 3 days apart
  • For each plaque causing the curvature deformity, up to four treatment cycles may be administered
  • Each treatment cycle consists of two injections given at six-week intervals for up to four cycles (maximum of 8 injections per plaque for the entire treatment course)

Approval:

  • Initial approval to assess patient’s response
  • Renew for 2 more injections if contracture persists
  • Maximum treatment 3 injections per cord

 

Last review date: July 20, 2016

Rite Aid Pharmacy Patients: All Rite Aid pharmacies nationwide are closing! Please be on the lookout for information from Rite Aid pharmacies about their bankruptcy and store closures. Call your Rite Aid pharmacy for questions about your prescriptions and new pharmacy options. WHA is here to help as well. Contact Us via Phone