Minocycline 24 hour (Solodyn®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Acne vulgaris

All of the following must be met as a condition for coverage (must include chart note documentation as supporting information):

  • Patient must have tried/failed generic minocycline AND generic doxycycline, with chart note support of reason for treatment failures (i.e., gastrointestinal side effects); note treatment failure due to ineffectiveness of minocycline or doxycycline is not considered towards Solodyn prior authorization approval
  • Must be prescribed/consulted by a dermatologist
  • Current weight is required

This Medication is Not Approvable for the following condition(s):

  • Any condition not listed above as an approved indication

The extended release product (Solodyn) is not FDA indicated for the following:

  • Acute intestinal amebiasis
  • Actinomycosis
  • Anthrax
  • Asymptomatic carriers of Neisseria meningitidis/li>
  • Campylobacter
  • Cholera
  • Clostridium
  • Gram-negative infections
  • Listeriosis
  • Mycobacterial infection
  • Ophthalmic infections
  • Relapsing fever
  • Respiratory tract infections
  • Rickettsial infections
  • Sexually transmitted diseases
  • Skin and skin structure infections>
  • Urinary tract infections
  • Vincent infection
  • Yaws>
  • Zoonotic infections

Dosing:

Extended release

  • Acne (inflammatory, non-nodular, moderate to severe): 1 mg/kg once daily for 12 weeks
  • Higher doses have not shown to be of additional benefit and may be associated with more acute vestibular adverse reactions
Minocycline ERa (Solodyn) Tablets Dosing
  Weight
  Tablet strength
  Actual dose
45 to 49 kg
45 mg
1 to 0.92 mg/kg
50 to 59 kg
55 mg
1.1 to 0.93 mg/kg
60 to 71 kg
65 mg
1.08 to 0.92 mg/kg
72 to 84 kg
80 mg
1.11 to 0.95 mg/kg
85 to 96 kg
90 mg
1.06 to 0.94 mg/kg
97 to 110 kg
105 mg
1.08 to 0.95 mg/kg
111 to 125 kg
115 mg
1.04 to 0.92 mg/kg
126 to 136 kg
135 mg
1.07 to 0.99 mg/kg
aER = extended release.
 
   
 
   
   

Approval: 

Six months (maximum effect may take upwards of 3-6 months)


 

Last review date: July 25, 2016

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