SOLODYN (minocycline 24 hour)
SELF ADMINISTRATION - ORAL
Indications for Prior Authorization:
- Acne vulgaris
All of the following must be met as a condition for coverage (must include chart note documentation as supporting information):
- Patient must have tried/failed generic minocycline AND generic doxycycline, with chart note support of reason for treatment failures (i.e., gastrointestinal side effects); note treatment failure due to ineffectiveness of minocycline or doxycycline is not considered towards Solodyn prior authorization approval
- Must be prescribed/consulted by a dermatologist
- Current weight is required
This Medication is Not Approvable for the following condition(s):
- Any condition not listed above as an approved indication
The extended release product (Solodyn) is not FDA indicated for the following:
- Acute intestinal amebiasis
- Actinomycosis
- Anthrax
- Asymptomatic carriers of Neisseria meningitidis/li>
- Campylobacter
- Cholera
- Clostridium
- Gram-negative infections
- Listeriosis
- Mycobacterial infection
- Ophthalmic infections
- Relapsing fever
- Respiratory tract infections
- Rickettsial infections
- Sexually transmitted diseases
- Skin and skin structure infections>
- Urinary tract infections
- Vincent infection
- Yaws>
- Zoonotic infections
Dosing:
Extended release
- Acne (inflammatory, non-nodular, moderate to severe): 1 mg/kg once daily for 12 weeks
- Higher doses have not shown to be of additional benefit and may be associated with more acute vestibular adverse reactions
| Minocycline ERa (Solodyn) Tablets Dosing | ||||||||
|---|---|---|---|---|---|---|---|---|
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|
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45 to 49 kg
|
45 mg
|
1 to 0.92 mg/kg
|
||||||
|
50 to 59 kg
|
55 mg
|
1.1 to 0.93 mg/kg
|
||||||
|
60 to 71 kg
|
65 mg
|
1.08 to 0.92 mg/kg
|
||||||
|
72 to 84 kg
|
80 mg
|
1.11 to 0.95 mg/kg
|
||||||
|
85 to 96 kg
|
90 mg
|
1.06 to 0.94 mg/kg
|
||||||
|
97 to 110 kg
|
105 mg
|
1.08 to 0.95 mg/kg
|
||||||
|
111 to 125 kg
|
115 mg
|
1.04 to 0.92 mg/kg
|
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|
126 to 136 kg
|
135 mg
|
1.07 to 0.99 mg/kg
|
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aER = extended release.
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Approval:
Six months (maximum effect may take upwards of 3-6 months)
Last review date: July 25, 2016