Amifampridine (Firdapse®)


Indications for Prior Authorization:
  • Treatment of Lambert-Eaton myasthenic syndrome (LEMS) in adults
Patients must meet the following criteria:
  • Chart note documentation is provided supporting the diagnosis of LEMS, AND
  • Prescribed by or in consultation with a neurologist, AND
  • Patient is age 18 years or older, AND
  • Documentation of a baseline clinical muscle strength assessment (examples may include but are not limited to the Quantitative Myasthenia Gravis (QMG) score, triple-timed up-and-go test (3TUG), Timed 25-foot Walk test (T25FW)), AND
  • Patient does not have a history of seizures
  • Positive clinical response to therapy (e.g. improvement in dynamometry, timed 25-foot walk test, timed up and go test) as confirmed by chart note documentation
  • Recommended starting dosage: 15 mg to 30 mg daily, taken orally in divided doses (3 to 4 times daily)
  • The dosage can be increased by 5 mg daily every 3 or 4 days
  • The maximum recommended total daily dosage is 80 mg
  • The maximum single dose is 20 mg
  • Initial: 3 months
  • Renewal: 1 year

Last review date: December 9, 2019

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