Delfampridine (Ampyra)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Indicated to improve walking in patients with multiple sclerosis (MS)

Patients must meet the following criteria for the indications above:

  • Diagnosis of MS confirmed by a neurologist AND
  • Creatinine clearance > 50 ml/min Ampyra is contraindicated in moderate - severe renal impairment AND
  • An EDSS score of <seven (patient must be ambulatory) Ampyra is contraindicated in patients with a history of seizure
    • Seizures in patients taking Ampyra should be reported to Acorda drug safety at 1-800-367-5109 or the FDA (1-800-332-1088)
  • All coverage requests must include the results of two walking studies as baseline data

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

  • All non-FDA approved indications

Dosing:

  • Ampyra 10 mg PO every 12 hours
  • Use of doses higher than 10 mg twice a day may increase the risk of seizure

Approval:

  • Ampyra therapy will be approved initially for a three month trial
  • Renewal requires chart note documentation of improvement in the patient's walking parameters such as distance and speed

 

Last review date: July 5, 2011

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