Tesamorelin (Egrifta)

Approved for: 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.

Initial approval for three months.

Renew for six months if patient demonstrates and maintains reduction in waist circumference.


Western Health Advantage Pharmacy and Therapeutics Committee

Approved:  May 2011

Last review date: July 21, 2016