Glycerol phenylbutyrate (Ravicti®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Treatment of adult and pediatric patients (> 2 years) patients with urea cycle disorders (UCD)

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

  • Patients symptoms cannot be managed with dietary protein restrictions and/or amino acid supplementation alone

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

  • All non-FDA approved uses not listed in the approved indications
  • Patient must be on protein restricted diet

Recommended Dosing:

  • Initial dose in treatment naïve patient is 4.5 to 11.2 mL/m2/day in three divided doses with food

Approval:

One year


 

Last review date: December 2, 2013

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.