ENDARI (l-glutamine oral powder)

ENDARI (l-glutamine oral powder)

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