Methylnaltrexone (Relistor ®)

SELF ADMINISTRATION - SUBCUTANEOUS SELF-INJECTION OR TABLETS

Indication(s) for Prior Authorization:

  • Injection and tablet: Opioid-induced constipation (OIC) in adults with chronic non-cancer pain
  • Injection: Opioid-induced constipation (OIC) in adults with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient

Patients must meet all the following criteria as a condition(s) for coverage:

  • Diagnosis of opioid induced constipation, AND
  • Inadequate response to conventional laxatives, AND
  • Inadequate response or intolerable side effects to stimulant laxatives, AND
  • For tablets: Patient has tried and failed Movantik

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

  • Disease states not listed above

Dosing:

  • OIC in adults with chronic non-cancer pain:
    • Tablets: 450 mg once daily in the morning
    • Injection: 12 mg subcutaneously once daily
  • OIC in adults with advanced illness:
    • Administered as 1 dose every other day, as needed
      • < 38 kg
        • 0.15mg/kg (round dose up to nearest 0.1ml of volume)
      • 38 to < 62 kg
        • 8 mg
      • 62-114 kg
        • 12 mg
      • > 114 kg
        • 0.15mg/kg (round dose up to nearest 0.1ml of volume)

 

Last review date: December 1, 2014