Telotristat ethyl (Xermelo)

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

Last review date: May 1, 2017