EGRIFTA SV (tesamorelin)

EGRIFTA SV (tesamorelin)

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