XERMELO (telotristat ethyl)

XERMELO (telotristat ethyl)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

• Treatment of carcinoid syndrome diarrhea in combination with somatostatin analog (SSA) therapy in adults inadequately controlled by SSA therapy

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

• Diagnosis of carcinoid syndrome diarrhea

• 18 years of age or older
• Patient is followed by a specialist (oncologist or gastroenterologist)
• Patient is inadequately controlled on maximum SSA therapy and needs additional therapy
• Approval for a maximum of 250mg three times daily

Dosing:

• 250mg orally three times daily with food

• If used in combination with short-acting octretotide, administer octreotide at least 30 minutes after telotristat ethyl

Approval:

• Initial: 3 months

• Renewal: 1 year