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
- Initial dose in treatment naïve patient is 4.5 to 11.2 mL/m2/day in three divided doses with food
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: March 2013 Reviewed: December 2013