Hydrocortisone Suppositories (e.g., Anucort-HC, Anusol-HC, Hemmorex-HC, Proctocort)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • For use in inflamed hemorrhoids, post-irradiation (factitial) proctitis, or as adjunct in the treatment of chronic ulcerative colitis, cryptitis, and other inflammatory conditions of anorectum and pruritus ani

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

  • Diagnosis of inflamed hemorrhoids, post-irradiation (factitial) proctitis, or to be used as adjunct in the treatment of chronic ulcerative colitis, cryptitis, and other inflammatory conditions of anorectum and pruritus ani
  • Patient has tried and failed dietary changes and preferred alternatives, including OTC (e.g., fiber, hydrocortisone, pramoxine, lidocaine, phenylephrine, sitz baths) as supported by medical records documentation.

Dosing:

  • Nonspecific proctitis: one suppository twice daily (morening and night) for two weeks
    • Severe cases: one suppository three times a day, or two suppositories twice daily
  • Factitial proctitis: recommended duration of therapy is six to eight weeks or less

Approval:

  • Quantity limited to FDA recommended dosing based on diagnosis and severity
  • Duration: Limited to 6 month approval

Last review date: June 19, 2017