ESBRIET (pirfenidone)
SELF ADMINISTRATION - ORAL
Indications for Prior Authorization:
- Treatment of idiopathic pulmonary fibrosis (IPF)
Patients must meet the following criteria for the indication(s) above:
- Diagnosis if IPF by pulmonologist
The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:
- All non-FDA approved uses not listed in the approved indications
Dosing:
- Dose should be titrated over 14 days
- Dose is 801 mg (three 267 mg capsules) three times a day
- Doses should be administered at the same times each day
- Higher doses are not approvable
- Dose modification is required for adverse events and elevated liver function tests
Approval:
One year
Last review date: December 1, 2014