Histrelin SC implant (Supprelin LA®)
Indications for Prior Authorization
- central precocious puberty
Patients must meet the following criteria for the indication(s) above.
Patients two years and older. Discontinue at age 11 years for girls and 12 years for boys.
All of the following must be met:
- Age between two and 12 years
- Trial/failure/adverse effects of leuprolide depot
- 0.3mg/kg/dose IM q month (Lupron Depot PED [one month])
- 11.25mg to 30mg IM q 3 months (Lupron Depot PED [3 month])
The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee.
- Idiopathic short stature
- Ovarian cancer
- Prophylaxis for chemo therapy induced gonadal injury
- One implant (50mg) q 12 months
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: January 2013 Reviewed: December 2013
Reviewed UC Davis Pediatrics Jan. 2013