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


One year

Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: March 2013 Reviewed: December 2013