Tesamorelin (Egrifta)

SELF ADMINISTRATION

Indications for Prior Authorization

  • HIV associated lipodystrophy

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

  • Use in combination with any form of growth hormone or mecasermin (IGF-1)
  • Any other diagnosis not listed in the approved indications

All of the following must be met:

  • Diagnosis of HIV associated lipodystrophy
  • Prescribed by an HIV specialist
  • Patient 18 years old or greater
  • CT Scan that shows excess visceral fat, or waist-to-hip ratio for male greater than 0.94 and for women greater than 0.88
  • Failure of at least six  months of supervised diet and exercise program
  • Patient does not currently have malignancy

Dosing:

  • The recommended dose is up to 2mg SubQ per day

Approval:

  • Initial approval for three months
  • Renew for six months if patient demonstrates and maintains reduction in waist circumference

 

Last review date: July 21, 2016

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