L-Glutamine Oral Powder (Endari)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Indicated to reduce the acute complications of sickle cell disease in adult and pediatric patients 5 years of age and older

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

  • Prescribed by specialist, AND
  • Patient is 5 years or older, AND
  • Chart note documentation confirms sickle cell disease and meets the following characteristics:
    • Three or more sickle cell associated moderate to severe pain crises in a 12-month period
    • Presence of sickle cell-associated pain that interferes with daily activities and quality of life
    • History of severe and/or recurrent acute chest syndrome, AND
  • Patient has tried and failed Hydroxyurea, AND
  • Tried and failed OTC/other available L-glutamine products

Dosing (Weight-Based):

  • <30 kg: 1 packet twice daily
  • 30-65 kg: 2 packets twice daily
  • >65 kg: 3 packets twice daily

Approval:

  • One year

Last review date: September 4, 2018