droxidopa (Northera®)

ORAL ADMINISTRATION

Indications for Prior Authorization:

  • Treatment of adult patients with symptomatic neurogenic orthostatic hypotension (NOH)

Patient must meet the following criteria for the above indications:

  • Patients must have NOH secondary to Parkinson’s disease, multiple system atrophy, pure autonomic failure, dopamine beta-hydroxylase deficiency or non-diabetic autonomic neuropathy
  • Patients must have tried/failed treatment with fludrocortisone and midodrine

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

  • For any indications not mentioned above

Dosing:

  • The recommended starting dose is 100 mg three times a day
  • Titrate up to a maximum dose of 600 mg three times a day

Approval:

2 weeks


 

Last review date: September 1, 2014