Capsaicin (Qutenza®) patch

Approved for: office administration

Indications for Prior Authorization

For diagnosis of Post herpetic Neuralgia (PHN)

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.

  • any other diagnosis not listed in the approved indications

All of the following must be met:

  • Inadequate response, intolerable side effect(s) or contra-indication to at least two oral drugs [e.g. tricyclic antidepressants, anticonvulsants, opioids] and a self-administered topical patch [e.g. lidocaine patch] used for PHN,

OR

  • If pt is ≥ 65 yrs old, inadequate response, intolerable side effect(s) or contra-indication to an oral drug [e.g. anticonvulsants, opioids] and a self administered topical patch [e.g. lidocaine patch] used for PHN

Dosing

Up to 4 patches per treatment session, and not more frequently than every three months.

Administration of Qutenza®:

  • Only physicians or health care professionals under the close supervision of a physician are to administer Qutenza®
  • Use only nitrile (not latex) gloves when handling Qutenza® and when cleaning treatment areas.
  • Burning and erythema reported in majority of patients treated with Qutenza®.
  • The drug is approvable for initial coverage for 3 months. Reauthorize yearly based upon continued response to treatment.

Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: January 22, 2013 Reviewed: December 2013