Bosentan (Tracleer®)

SELF ADMINISTRTION - ORAL

Indications for Prior Authorization:

  • Indicated for the treatment of pulmonary hypertension to improve exercise ability

Patients must meet the following criteria for the indication(s) above:

  • Diagnosis of primary pulmonary hypertension class II, III, or IV symptoms confirmed by a cardiologist/pulmonologist/rheumatologist

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • Peripheral vasoconstriction
  • Patients on tadalafil or sildenafil therapy
  • All non-FDA approved uses not listed in the approved indications

Dosing:

Patient < 40 Kg

  • Tracleer: 62.5 mg twice a day
  • Maximum dose: 125 mg per day

Patient > 40 Kg

  • Tracleer: Start at 62.5 mg twice a day for 4 weeks, then 125 mg twice a day
  • Maximum dose: 250 mg per day; adjust dose for impair liver function

Approval:

One year


 

Last review date: December 2, 2013